LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP PATIENT REGISTRATION

3851 Katella Avenue, Suite 150

Los Alamitos, Caifornia 90720

Telephone: 562.314.1400

Fax: 562.431.0564

www.losalamitosortho.com

hank you for choosing Los Alamitos Orthopaedic Medical & Surgical Group. We look forward

to your first visit with us. In order to ensure that we do the best job possible and address all your

specific issues, it would be very helpful if you would please complete this registration packet before

your initial visit.

We have included a checklist for your convenience to assist you with all the various forms and

information needed. Be assured that all the information provided will assist us in assessing

your needs.

Please remember to bring your insurance card, co-pay and any authorizations and referrals that

apply to your visit. It would also be helpful to bring Xrays, MRI results and or any medical reports

available.

If you have any questions, please feel free to call our office for assistance.

Thank you,

Los Alamitos Orthopaedic Medical & Surgical Group

T

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP PATIENT REGISTRATION

3851 Katella Avenue, Suite 150

Los Alamitos, Caifornia 90720

Telephone: 562.314.1400

Fax: 562.431.0564

www.losalamitosortho.com

Patient Registration (Check List)

1. Patient Registration - administrative and insurance information (signature needed)

2. Health History (3 pages) - it is very important to have an accurate medical history in order to move forward

3. Osteoporosis Questionaire - helps to assess your risk and ensure your bone health

4. Privacy Notice Acknowlegement (3 pages) - government policies concerning privacy (signature needed)

5. Permission for Phone Messages - permission to leave messages on your phone (signature needed)

6. Financial Policy - clarification of financial responsibilities (signature needed)

7. Office Policy - explanation of our office policies

8. Medical Records - authorization for the doctor to release/receive information (signature needed)

Along with this registration packet, please also remember to bring:

1. Insurance card with any co-payment, co-insurance or deductible payments

2. Authorizations, referrals, Xrays, CDs, MRI

Please make sure you have completed ALL of the following forms and remember to bring them to your first

appointment.

Primary Insurance: Phone:

Plan ID Number: Group Number:

Insurer’s Name: Insurer’s Social Security#:

PPO In Network PPO Out of Network Commercial/Indemnity Medicare

Secondary Insurance: Phone:

Plan ID Number: Group Number:

Insurer’s Name: Insurer’s Social Security#:

PPO In Network PPO Out of Network Commercial/Indemnity Medicare

Insurance Yearly Effective Date: Deductible Amount: $

Has the Deductible been met this year? Yes No What is remaining? $

CoPay for Office Visits: $ CoInsurance%: $

Patient Name:

Home Address:

Home Phone: Cell Phone:

Email:

Emergency Contact: Emergency Phone:

Gender: Male Female

Marital Status: Single Married Separated Divorced Widow/er

Birthdate: Age: Social Security#:

Primary Care Physician: Phone:

Referred by (doctor/patient/friend):

Patient’s Employer/School:

Reason for today’s visit:

INSURANCE INFORMATION:

Last First Middle Initial Nickname

Street Apt#

City State Zip

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 1. PATIENT REGISTRATION

I request that payment of authorized Medicare or insurance benefits be made to my physician on my behalf for any services furnished to me by any of the physicians at Los Alamitos Orthopaedic Medical and Surgical Group. I authorize any holder of medical information about me to release to my insurance any information needed to determine these benefits. I authorize treatment of the person named above and agree to pay all fees and charges for such treatment, and I accept financial responsibility for non-covered services.

Signature Date

Please take a few minutes to complete this form. By doing so you will help your physician to provide the best medical care possible. Thank you.

NAME: AGE: DATE:

CURRENT ISSUE:

Main problem you are coming in for today? Onset Date:

Were you recently injured or suffered any trauma?

On a scale from 1 to 10 (10 being the worst) What is your CURRENT pain level?

Where is your pain located?

What is the quality of your pain? Sharp? Dull? Achy? Other?

How long have you had this problem?

What is the timing of your problem? Constant? Occassional? Morning? Evening? Other?

Do you have any mechanical symptoms? Popping? Clicking? Grinding? Other?

Is there anything that makes it worse? Activity? Non Activity? Other?

Have you had any of the following diagnostic studies within the last 6 months pertaining to this body part?

X-Ray Date Location

CT Scan Date Location

Myelogram Date Location

EMG / Nerve Conduction Date Location

MRI Date Location

Arthrogram Date Location

Have you completed any of the following treatments for this body part in the past?

Injections Date Type

Medication Date RX name

Physical Therapy Date Location

Bracing Date Location

Other Treatment:

REVIEW OF SYSTEMS:

Please list all medications you are currently taking:

page 1 of 3

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 2. HEALTH HISTORY

Do you have any allergies to medications or anything else? If yes, please explain:

List ALL surgeries you have had:

Please list your medical problems (Bleeding Disorders / Arthritis / Diabetes / Osteoporosis / Etc?) Please explain:

Have you ever been hospitalized or been under medical care for very long? If yes, for what reason?

Do you have any CURRENT symptoms related to the following (please circle or explain):

General Health (Fever / Weight Change) NO YES EXPLAIN:

Eyes (Eye Disease / Double Vision / Headache / Glaucoma) NO YES EXPLAIN:

Ears/Nose/ Throat (Nosebleeds / Ear Disease / Dizziness) NO YES EXPLAIN:

Neck (Stiffness / Thyroid / Enlarged Glands) NO YES EXPLAIN:

Cardiovascular (Chest Pain / Heart Trouble / High Blood Pressure / Swelling / Murmur) NO YES EXPLAIN:

Respiratory (Difficulty Breathing / Asthma / Pleurisy / Pneumonia) NO YES EXPLAIN:

Gastrointestinal (Ulcer / Liver Trouble / Gall Bladder / Bowels / Hepatitis / Diarrhea) NO YES EXPLAIN:

Skin (Rashes / Hives / Jaundice / Infection / Pigmentation) NO YES EXPLAIN:

Neurologic (Numbness / Tingling / Paralysis / Convulsions / Psychiatric Care) NO YES EXPLAIN:

Endocrine (Thyroid / Hormone Therapy / Diabetes) NO YES EXPLAIN:

Hematologic (Anemia / Phlebitis / Excess Bleeding / Blood Disease) NO YES EXPLAIN:

Urologic (Frequent or Painful Urination / Kidney Problems / Blood in Urine) NO YES EXPLAIN:

Musculoskeletal (Varicose Veins / Weakness of Muscles or Joints / Pain while Walking) NO YES EXPLAIN:

Have you ever had a major infection? If yes, please explain:

Is there any MAJOR Medical issues that run in your family? (Bleeding Disorders / Arthritis / Diabetes / Gout / Osteoporosis / Etc?) Please explain:

Have you or anyone in your immediate family experienced: Blood Clots / DVT / Pulmonary Embolism. If yes, please list:

SOCIAL HISTORY:

Do you live: Alone w/Spouse w/Family Apt/Condo House Assisted Living

Caffeine: NO YES How Much:

Smoke: NO YES Former When did you quit?

Alcohol: NO YES Type/Frequency:

Recreational Drugs: NO YES Type/Frequency:

Are you exposed to fumes, dusts or solvents? NO YES

Education: High School College Postgraduate

Are you currently working? NO YES DISABLED (if No) date last worked

page 2 of 3

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 2. HEALTH HISTORY

Patient Name (Nombre): Date (Fecha):

Mark the area on your body where you feel the described sensations.

Numbness Tingling Burning Stabbing Aching Cramping Sensitive Other

0000 tttt xxxx //// ==== cccc ssss pppp

Marke el area en su cuerpo donde usted siente Ias sensaciones descriptas.

Adormecido Hormiguero Quemando Cuchillada Adolorido Calambre Sencible Otro

0000 tttt xxxx //// ==== cccc ssss pppp

Signature (Firma): Date (Fecha):

L R R L

page 3 of 3

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 2. HEALTH HISTORY

DATE:

NAME: DATE OF BIRTH:

DATE OF LAST DEXASCAN:

LOCATION TAKEN: DOCTOR:

RISK FACTOR INFORMATION:

Height: Weight:

Race: Caucasian Asian Hispanic African American

Menstrual Status: Regular Irregular Menopause/When? Yes No

History of fractures in relatives over 65 yrs? Yes No

If yes, state relation and which bones:

Have you had any recent falls? Yes No

When?

Steroids use? Yes No

Impaired vision? Yes No

Liver problems? Yes No

Current smoker? Yes No

How many years? How many packs per day?

Low calcium intake? Yes No

Lactose intolerant? Yes No

Physically active? Yes No

Alcohol intake? Yes No

More than 2 drinks per day? Yes No

Hyperthyroidism or Thyroid Replacement Therapy? Yes No

Kidney problems? Yes No

Have you ever been diagnosed with Osteoporosis? Yes No

Male sexual problems? Yes No

Prolonged immobilizations? Yes No

Stomach problems? Yes No

Heartburn? Yes No

Medication? Yes No

Irritable bowel? Yes No

Gastric bypass? Yes No

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 3. OSTEOPOROSIS HISTORY

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS

INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your confidentiality is maintained my restricting access only to employees who need access to your PHI in order to process services. Also, we have

implemented appropriate physical, electronic and procedural safeguards to protect you PHI against any unauthorized use or disclosure. Our staff is

required to complete and annually review a training program designed to protect you PHI. Although there are many safeguards to protect your PHI,

there are some instances where Federal and State laws allow us to use/disclose your information without your consent.

These are:

1. To provide your health care services.

2. To bill and collect payments for the health care services provided.

3. To provide you with treatment alternatives.

4. To inform you about health benefits and services.

5. To remind you of your appointments.

6. To complete health care operations such as to resolve an appeal or a grievance.

7. When required by law.

8. For public health activities.

9. For health oversight activities.

10. For reports about child and other types of abuse or neglect or domestic violence.

11. For lawsuits or other legal purposes.

12. For law enforcement purposes.

13. To report to coroners, medical examiners or funeral directors.

14. For tissue or organ donations.

15. For research.

16. To avert a serious threat to the health or safety or you or others.

17. For national security and intelligence/military activities.

18. In connection with services provided under workers’ compensation laws.

19. To family members or persons who are involved in your care or payment of care.

20. To create a directory that includes your name, your location at the facility, your general condition and your religious preferences when you

are in an affiliated hospital.

You may agree or object to this disclosure. If you cannot agree or object because you are incapacitated or otherwise unavailable, we will use our

professional judgment. If you are a parent, you may control your minor child’s PHI. There are some cases when we are permitted or even required by the

law to deny your access to your child’s PHI, such as when your child can legally consent to medical services without your permission. There are some

types of PHI, such as HIV test results or mental health information, which are protected by stricter laws. However, even this PHI may be used or disclosed

without your written authorization if required or permitted by law. All other uses and disclosures of your PHI require your written authorization. If you

need an arbitration form, we will send you one for you or your personal representative to complete. When you receive the form, please fill it out and send

it to the following address:

Attention: Carol Olivarez, Privacy Officer

Los Alamitos Orthopaedic Medical and Surgical Group

3851 Katella Avenue, Suite 150

Los Alamitos, California 90720

page 1 of 3

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 4. PRIVACY NOTICE

NOTICE OF PRIVACY PRACTICES (continued)You may revoke or modify your authorization at any time by writing to us at the same address. Please note that your revocation or modification may not be

effective in some circumstances, such as when you have already taken action relying your authorization. You also have the right to review and copy any of

your PHI that we possess. If you wish to see your PHI, please write to us and we will tell you when and where you can review your PHI in our possession

within our normal business hours. If you would like a copy of the information we have, please write to us at the same address. If we provide you with a

copy, we may charge a reasonable administrative fee for copying your PHI to the extent permitted by applicable law. If we deny your request for review or

copy of your PHI, we will explain the reason in writing. If we do not have your PHI, but know who does, we will tell you whom to contact. If you wish to

have your PHI corrected or updated, please write to us and tell us what you want changed and why. We will respond to you in writing, whether accepting

or denying your request. If we deny your request, we will explain why. You may also send us an addendum that is no longer than 250 words in length for

each item you believe is incorrect. Please clearly indicate that you want the addendum to be included in your PHI. We will attach your addendum to the

record(s) of your PHI. Your amended PHI will be available for your review upon request. You have the right to request an accounting of certain disclosures

that we make of your PHI by writing to us. Please note that certain disclosures, such as those made for treatment, payment, or health care operations,

need not be included in the accounting we provide to you. We will respond to your request within a reasonable period of time, but no later than 60 days

after we receive your written request. You have the right to request and receive a paper copy of this Notice. You have the right to restrict restrictions on

how we use and disclose you PHI for our treatment, payment and health care operations. All requests must be made in writing. Upon receipt, we will review

your request and notify you whether we have accepted or denied your request and notify you whether we have accepted or denied your request. Please

note that we are not required to accept your request for restriction. Your PHI is critical for providing you with quality health care. We believe we have

taken the appropriate safeguards and internal restrictions to protect your PHI, and that additional restrictions may be harmful to your care. You have the

right to request that we provide your PHI to you in a confidential manner. For example, you may request that we send your PHI by alternate means, (e.g.

sending you a sealed envelope, rather than a postcard) or to an alternate address (e.g. calling you at a home address). We will accommodate any reason-

able requests, unless they are administratively too burdensome, or prohibited by law. We must follow the privacy practices set forth in this Notice while in

effect. If you have any questions about this Notice, wish to exercise your rights, or file a complaint, please direct your inquires to:

Carol Olivarez, Privacy Officer

Los Alamitos Orthopaedic Medical and Surgical Group

3851 Katella Avenue, Suite 150

Los Alamitos, California 90720

You may contact your Health Plan or the California Department of Managed Care with your concerns as well. You also have the right to directly

complain to the Secretary of the United States Department of Health and Human Services. We will not retaliate against you for filing a complaint against

us. We will use and disclose your PHI to the fullest extent authorized by law. We reserve the rights as expressed in this Notice. We reserve the right to

revise our privacy practices consistent with the law and make them applicable to your entire PHI we possess, regardless of when it was received or created.

If we make material or important changes to our privacy practices, we will promptly revise our Notice. Unless law requires the changes, we will not

implement material changes to our privacy practices before we revise our Notice. You may request updates to this Notice at any time.

Effective: June 1, 2004

page 2 of 3

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 4. PRIVACY NOTICE

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record.

We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your

record or get more information about it by contacting the administrator of the location at which you have been treated. Please call the main

office phone number and ask for the administrator.

Our Notice of Privacy Practice describes in more detail how your health information may be used and disclosed, and how you can access your

information.

By my signature below I acknowledge receipt of the Notice of Privacy Practices.

Patient or legally authorized individual signature Date Time

Printed name if signed on behalf of the patient Relationship

(parent, legal guardian, personal representative)

This form will be retained in your medical record

page 3 of 3

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 4. PRIVACY NOTICE

PERMISSION TO LEAVE PHONE MESSAGES

Dear Patient:

HIPPA privacy guidelines prevent us from leaving messages for you regarding appointments or any other medical matter.

In order to efficiently communicate with you regarding appointment confirmations, changes or availability please sign below,

thereby giving us permission to leave a message on your answering machine, service or with a family member.

This waiver will apply only to messages regarding your appointment(s) or the need for the Doctors or their staff to speak with you

regarding procedures or results. No other medical information will be communicated.

I give permission for the Doctor’s or their staff to leave phone messages with:

Family members: YES NO

Answering machine/service: YES NO

Patient’s Name (PRINT)

Patient’s Signature Date

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 5. PHONE PERMISSION

It is important to clarify our financial policy with each patient. This prevents misunderstanding and unnecessary hard feelings.

We make every effort to keep the cost of medical care down.

If you have insurance, as a courtesy we will bill the insurance company for you. Please understand that insurance policies represent an

agreement between you and your insurance company. You are responsible for the payment of your bill regardless of the status of your claim.

All patient co-payments and coinsurance are to be paid in full at the time services are rendered. Cash, check, Visa and Mastercard are

accepted. Telephone verification of your insurance coverage does not guarantee the claim will be paid. If you are dissatisfied with your

insurance company’s processing or payment of your claim, it will be your responsibility to arbitrate this matter with them. We will be glad to

supply you with a copy of the claim for arbitration. Should your insurance payments for claims be sent directly to you, whether primary or

secondary insurance companies, this should be used to pay outstanding charges for which you are financially responsible. Please desposit the

insurance check and send us a personal check or forward the insurance check as soon as possible.

Surgical Fees

The insurance company will be billed following surgery; however the patient responsibility portion will be due and payable at your first

post-operative office visit. At your request, an estimate of those fees will be made for you prior to your surgery. This will only be an estimate

based on the expected procedures and services performed. If the insurance company does not pay for the service provided it is the patient’s

responsibility to pay the balance within 30 days from the date of surgery.

Insurance Contracts and our office

Contracts between the insurance companies and our office change continually. You may call our office to see if your insurance is currently

accepted. We are NOT contracted with Medi-Cal. You will be notified by mail if we no longer accept your insurance. You have the option at that

time to continue treatment with our physicians by accepting all financial responsibility for your medical treatment or you may have your care and

medical records transferred to another physician of your choice.

Returned Check Policy

A $25.00 fee will be charges for all returned checks.

Payment by cashier’s check or money order will be required to replace the dishonored check.

I have read the above financial policy and understand and accept my responsibilities as a patient.

Signed Date

Witnessed Date

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 6. FINANCIAL POLICY

OFFICE HOURSMonday though Thursday – 8:00 am - 5:00 pm

Fridays – 8:00 am - 4:00 pm

Closed for lunch (12:00 - 1:30)

DIRECTIONSFrom the 405 Fwy: exit Seal Beach Blvd. Go east to Katella. Turn right on Katella. Turn left on Kaylor Street. The parking entrance will be on your

right.

From 605 Fwy: exit at Katella/Willow. Go south on Katella. Follow Katella approximately 1/2 mile. Turn left on Kaylor Street. The parking entrance

will be on your right.

APPOINTMENT POLICYIn order to provide our patients with timely scheduling options, the following office policies are now in place at our office.

Please become familiar with them.

Changes to Appointments:

We require a minimum of 24 hours notice to change the time or date of your appointment. Please contact the scheduling desk to request a change.

If you are delayed and cannot be on time for your appointment kindly call the office. Please be aware that it may not be possible to see your

Doctor that same day however, we will make every effort to do so.

Cancellations and No Shows:

Patients will be charged $25.00 for each “No Show” or cancellation not made at least 24 hours before the scheduled appointment.

FORMS COMPLETIONThere is a $25.00 form fee that applies to outside forms requested for completion by our office (other than EDD).

Fees are due at the time the forms are brought to the office. Forms will not be completed before fee is paid.

Please allow 10 business days for processing of all forms.

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 7. OFFICE POLICY

AUTHORIZATION TO RELEASE OR RECEIVE CONFIDENTIAL MEDICAL RECORDS

Patient Name Date of Birth

Doctor requesting/sending records

Doctor or hospital to relinquish or receive records

Address: Los Alamitos Orthopaedic Medical and Surgical Group

3851 Katella Ave. Suite 150

Los Alamitos, CA 90720

Telephone: 562-314-1400

Fax: 562-431-0564

This authorization to receive/release confidential medical records is to comply with the terms of the appropriate governing codes,

including California civil section 56 et.seq., California evidence code section 115B and other.

The undersigned, hereby authorizes the party listed above to furnish or receive from the above the following requested

medical information:

X-Ray Reports All Medical Records Other:

X-Ray Films Laboratory Reports

This authorization shall become effective immediately and shall remain in effect as long and as necessary the person requesting/receiveing to

fulfill obligations requested.

Photocopy of this authorization shall be considered as valid as the original.

Patient Name Date

Signature

LOS ALAMITOS ORTHOPAEDIC MEDICAL & SURGICAL GROUP 8. MEDICAL RECORDS