New Patient - Golden Coast Medical Associates

NOTICE OF PRIVACY PRACTICE SUMMARY

This summary discloses how health information about you may be used. A full notice of your privacy rights is available upon request.

Golden Coast Medical Associates uses health information about you for treatment, to obtain payment for treatment with your authorization as required, for administrative purposes, and to evaluate the quality of care that you receive.
Golden Coast Medical Associates will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.
Golden Coast Medical Associates may use your information to provide appointment reminders, information about treatment alternatives or other health-related issues.
Golden Coast Medical Associates may disclose your information for public health activities, research, health and safety, governmental function in order to comply with workers compensation laws and regulations, a right to request Restriction, report and retain a copy of your health record, request communication of your information by alternative means at alternative locations, revoke your authorization and request an accounting of your health records.
Golden Coast Medical Associates must maintain the privacy of protected health information (PHI), provide you with notice of its legal duties and privacy practices with respect to your health information, abide by the terms of the notice, notify you if it was disclosed, accommodate reasonable requests you may make to communicate with health information by alternative means or by alternative locations and obtain your written authorization to use or disclose your health information for reasons other than those listed above permitted under law.

If you have any questions or concerns, please contact Norma Garcia, Privacy and Security Officer, at (702) 499-4124.

Patient Signature

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

Medical Lien Agreement

Attorney:

Supraja Thota, MD 10717 Camino Ruiz Suite 164 San Diego, CA 92126 Phone: (619) 808-8977 Fax: (866) 531-4083

I authorize Dr. Supraja Thota, MD to furnish you, my attorney/insurance carrier, with a full report of any medical care and treatment I received with regard to my accident/illness which occurred/began

Date

I understand this may include a report of my prior medical history, examination, diagnosis, treatment, prognosis, and/or recommendations for future treatment. I agree that Dr. Supraja Thota, MD may disclose my protected health information to the above-listed attorney/insurance carrier and I hereby waive any associated privilege.

I agree to provide this priority lien to Dr. Supraja Thota, MD on any settlement, claim, judgment or verdict as a result of my accident/illness. I accordingly direct you, my attorney/insurance carrier, to pay directly to Dr. Supraja Thota, MD such sums as may be due and owing them for all services rendered to me by reason of this accident/illness. I request you pay Dr. Supraja Thota, MD within sixty (60) days of receipt of any proceeds and satisfy this lien in full before disbursing any funds to me or any other claimant against said funds. I authorize and instruct you to satisfy this lien from my client trust account and/or to withhold sums from any settlement, judgment, or verdict as may be necessary to pay said Dr. Supraja Thota, MD’s billings in full.

I acknowledge and agree that I, as the patient, am directly and fully financially responsible to Dr. Supraja Thota, MD for all services rendered to me. I understand that payment is not contingent on any settlement, claim, judgment, or verdict. I understand this lien is made solely for Dr. Supraja Thota, MD’s protections and in consideration for awaiting payment. I understand that by accepting this lien Dr. Supraja Thota, MD is not providing a guarantee of a diagnosis, treatment, prognosis or recommended future treatment.

I agree that it is my responsibility to apprise Dr. Supraja Thota, MD of all information regarding my claim and agree to respond to any such requests for information within thirty (30) days. I understand that if I do not respond to a request for information within thirty (30) days, or if Dr. Supraja Thota, MD is not paid for services rendered pursuant to this lien within sixty (60) days from my receipt of any proceeds and/or final billing, my account will accrue interest at a rate of twelve percent (12%) per annum from the date services were first rendered. Further, I agree to be responsible for all fees and costs incurred by Dr. Supraja Thota, MD to enforce this agreement. I wave any applicable statute of limitations to the enforcement and collection of this lien.

I understand that in the event I discharge my attorney prior to payment in full of all medical billings due to Dr. Supraja Thota, MD, my account will become immediately due and owing unless a new attorney is engaged and endorses this lien with thirty (30) days.

By signing below, I am agreeing to the above medical lien. I understand and agree all of the provisions of this Agreement shall remain in full force and effect until revoked by me in writing. I understand this lien is enforceable against me whether or not signed by my attorney/insurance carrier.

Patient Printed Name(Required)

SS#

Patient Signature

Date

The undersigned being the attorney of record/authorized representative of the insurance carrier for the above patient does hereby agree to all terms of the above and agrees to withhold such sums from any settlement, judgment, or verdict as may be necessary to honor completely the above referenced lien. The undersigned also agrees that prior to disbursement of any settlement, judgment, or verdict proceeds she/he will contact Dr. Supraja Thota, MD’s office. Should the undersigned withdraw or be discharged from representing, the above-named patient, she/he agrees to contact Dr. Supraja Thota, MD’s office with 5 days in writing to apprise them of same.

Attorney Name

Phone

Date

Pain Drawing

Name

Date

Please be sure to fill this out extremely accurately. Mark the area on your body where you feel the described sensation(s). Using the appropriate symbols, mark areas of pain, include all affected areas, as you feel right now. You may draw in the face as well.

Body

Visual Analogue Scale

Make one mark through the line below to represent your current level of pain, with 0 representing no pain at all, and 10 representing the worst possible pain.

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

VEHICLE DRAWING

Name

Date

Please be sure to fill this out extremely accurately. Mark the area where you were seated at time of accident. Using the appropriate symbols, to mark the area of impact.

Vehicle

Signature of Patient/Guardian

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

AUTO HISTORY

Name

Date

Date of accident

Type of collission

Head-on

Left side impact

Right side impact

Rear-end collission

Was your vehicle stopped?

Yes

Where were you seated in the vehicle?

Driver

Passenger

Front

Back

List any parts of your body that made contact with the vehicle:

Were you knocked unconscious?

Yes

Did you receive medical care after the accident?

Yes

Did you go to a hospital or urgent care clinic?

Yes

What was the name & location of the hospital/clinic?

If you went to a hospital, were you transported by ambulance?

Yes

Have you seen any other doctors?

Yes

What is the doctor's name?

Were x-rays taken?

Yes

Were you given pain medication?

Yes

Were you given muscle relaxants?

Yes

Were you given any other treatments?

Yes

Explain

Where do you currently have pain?

Please explain

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

HEALTH QUESTIONNAIRE

Name

Date

Past Medical History

PRE-EXISTING CONDITIONS:

Have you sought care for any health condition in the past 3 years?

Yes

What condition(s)?

What treatment was administered?

Do you take medication for any condition?

Yes

What medication(s)?

Have you ever had a surgery?

Yes

What type of surgery?

Social History:

Alcohol:

Yes

Limit

Rare

Social

Regular

Smoke:

Yes

How many packs per day

Illicit Drugs:

Yes

Limit

Family Hisory:

Hypertension:

Mother

Father

Sibling

N/A

Diabetes:

Mother

Father

Sibling

N/A

Cancer:

Mother

Father

Sibling

N/A

Cardiac Issues:

Mother

Father

Sibling

N/A

Stroke:

Mother

Father

Sibling

N/A

Mental Illness:

Mother

Father

Sibling

N/A

Have you had any previous automobile accidents, work injuries, sports injuries, fractures, or other accidents/injuries?

Yes

Give date and describe

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

Name

Date

Systematic Review:

General:

Fever

Yes

Unsual weight loss

Yes

Weakness

Yes

Skin:

Abnormal pigmentation

Yes

Hives

Yes

Eczema

Yes

Rash

Yes

Ecchymosis

Yes

Heent:

Blurred Vision

Yes

Double Vision

Yes

Glaucoma

Yes

Eye Injury

Yes

Eye Disease

Yes

Respiratory:

Chronic Cough

Yes

Asthma

Yes

Wheezing

Yes

Pleurisy

Yes

Pneumonia

Yes

Neck:

Shortness of breath

Yes

Stiffness

Yes

Pain

Yes

Thyroid Trouble

Yes

Enlarged Glands

Yes

Neurological:

Headaches

Yes

Confusion

Yes

Dysarthia

Yes

Weakness

Yes

Numbness

Yes

Cardio Vascular:

Chest Pain

Yes

Shortness of Breath

Yes

High Blood Pressure

Yes

Congestive Heart Failure

Yes

Heart Murmur

Yes

A-Fib

Yes

Pacemaker

Yes

Psychological:

Anxiety

Yes

Depression

Yes

Mood Changes

Yes

Gastrointestinal:

Nausea

Yes

Vomiting

Yes

Diarrhea

Yes

Constipation

Yes

Blood in stool

Yes

Heartburn

Yes

Gallbladder Disease

Yes

Liver Disease

Yes

Hepatitis

Yes

Allergies:

Allergies to Medication

Yes

Which Medication

Hematological:

Are you slow to heal after cuts?

Yes

Blood disease

Yes

Anemia

Yes

Phlebitis

Yes

Have you had any abnormal bruising or bleeding?

Yes

Signature of Patient or Parent/Guardian of Minor Child:

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

PATIENT INFORMATION:

Name

Date

Address

City

State

Zip Code

Home Phone

Cell Phone

DOB

Sex

Male

Female

SS#

Marital Status

Single

Married

Divorce

Separated

Appointment text reminders(Required)

I authorize appointment text reminders

I do not want to receive text reminders

Preferred Pharmacy

Phone #

Employer

Phone #

Employer Address

Email #

City

State

Zip Code

Name of Spouse

Phone #

Emergency Contact

Phone #

Date of Injury

How were you injured?

Auto Accident

Slip & Fall

Work

Other

Explain

Do you have an attorney?

Yes

Who is your attorney?

Attorney Address

Phone #

Signature of Patient or Parent/Guardian of Minor Child

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

CONTRACT FOR CONTROLLED SUBSTANCES

Controlled substance medications (narcotics and benzodiazepines) may be very useful but have a high potential for misuse and abuse and are, therefore, closely controlled by the state and federal governments. Used properly, they are very effective medications. If used excessively, however, they may cause adverse effects. To ensure these medications are used properly, I agree to the following conditions:

I am responsible for my controlled substance medications. If the prescription or medication is lost, misplaced, or stolen, or if I use it up sooner than prescribed, I understand that it will not be replaced.
I will not request, nor accept, controlled substance medication from any other provider while I am receiving such medication from my Golden Coast Medical Associates provider, except if I am a patient in a hospital. Besides being illegal (NRS 453.391), it may endanger my health.
REFILLS of controlled substance medications and tranquilizers will REQUIRE an IN-OFFICE visit during regular office hours of 9AM to 6PM, MONDAY through FRIDAY.
I understand that if I violate any of the above conditions and/or decline to take a urine drug test at my provider's request, my controlled substance prescriptions will end immediately. If the violation involves obtaining controlled substance medications from another individual, as described above, I may also be reported to my primary care provider (physician, physician assistant, or nurse practitioner), local medical facilities, and other authorities.

I have been informed by my provider about narcotic and tranquilizer effects, including normal physiologic effects of tolerance (need for more medicine to achieve the same pain relief) and dependence (withdrawal will occur if I stop the medicine abruptly) and addiction (abnormal psychological dependence.)

Patients Printed Name

Patients Signature

Date & Time

Witness Printed Name

Date & Time

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

URINE TOXICOLOGY

If controlled substances (Narcotics or Anxiolytics) are prescribed, a urine toxicology test will be performed in house. All urine tests done in house will be sent out for outside lab confirmation.

By signing this document, I understand that this will incur additional charges.

Patients Printed Name

Patients Signature

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

INFORMED CONSENT FOR

CONTROLLED SUBSTANCE TREATMENT FOR PAIN

California law requires a patient’s informed consent before a controlled substance can be initially prescribed to treat the patient’s pain. I understand that attempting to reduce my pain is my responsibility, and that the treatment of pain with controlled substances carries with it some additional responsibilities which my practitioner has made me aware. The purpose of this agreement is to help both me and my practitioner comply with the law. (Please initial each numbered paragraph and sign below to indicate your understanding of all parts of this document.)

POTENTIAL RISKS AND BENEFITS OF USING A CONTROLLED SUBSTANCE FOR THE TREATMENT OF PAIN INCLUDING RISKS OF DEPENDENCY, ADDICTION AND OVERDOSE

I have read and understand each of the statements written above and have had an opportunity to have all my questions answered. By signing, I provide consent for the prescription of controlled substances for the treatment of pain.

Patient Signature

Patient name printed

Date

For a minor, or for a legal guardian:

Parent/Guardian

Parent/Guardian name printed

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

PATIENT LIEN

Date

Patient's Name

SS#

THIRD PARTY INSURANCE INFORMATION:

Insurance Company

Claim #

Adjuster's Name

Policy #

Phone #

Fax #

Address:

YOUR AUTOMOBILE INSURANCE INFORMATION:

Insurance Company

Claim #

Adjuster's Name

Policy #

Phone #

Fax #

Address:

Date of accident

I agree to pay said doctor within 10 days of a settlement being made.

Signature of Patient/Guardian

Date

Signature of Witness

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

ASSIGNMENT OF BENEFITS AGREEMENT

Patient Name

Date of Accident

Insured/Guardian's Name

Patient Signature

(Patient or Minor Child Guardian/Parent)

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

THIRD PARTY ASSIGNMENT OF BENEFITS AGREEMENT

Patient Name

Date of Accident

Patient Signature

(Patient or Minor Child Guardian/Parent)

Date

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

Request for Patient Records

10717 Camino Ruiz Suite 164
San Diego, CA 92126
Office: 619-808-8977
Fax: 866-531-4083

Date

Name

Social Security No.

Date of Birth

Date of Incident

Date of Treatment

TO PRESENT

I hereby authorize release of my health information as set forth below:

The following individual and/or organization is authorized to make the disclosure:

Section Break

Phone

Fax

The type and amount of information to be used and disclosed is as follows:

All medical Records

History & Physicals

Consultation Reports

Discharge Summaries

Operative Reports

Lab / Pathology Records

Radiology Reports/ Images

Emergency Room Records

Date

Signature

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

SLIP & FALL HISTORY

Patient

Date

Date of Accident

Type of fall

Tripped

Fell

Slipped

Other

Expalin

Type of surface

Obstruction

Wet Floor

Food/ Liquid on floor

Hole in ground / Pavement

Obstruction

Explain

Did you hit your body against floor/ground/object

Were you knocked unconscious

Yes

Did you go to the Hospital/ Quick Care Center

Yes

By Ambulance

Yes

Name & Location of Hospital /Quick Care Center

Have you seen any other doctors

Yes

Drs. Name

Were you given pain medication

Yes

Muscle Relaxants

Yes

Other treatment

Where do you have currently have pain

Explain

Describe what happened

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

BECK ANXIETY INVENTORY (BAI)

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by hat symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

Numbness or tingling

Feeling hot

Wobbliness in legs

Unable to relax

Fear of worst happening

Dizzy or lightheaded

Heart pounding / racing

Unsteady

Terrified or afraid

Nervous

Feeling of choking

Hands trembling

Shaky / unsteady

Fear of losing control

Difficulty in breathing

Fear of dying

Scared

Indigestion

Faint / lightheaded

Face flushed

Hot / cold sweats

About: This scale is a self-report measure of anxiety.

Item: 21

Reliability:
Internal consistency for the BAI = (Cronbach’s a=092) Test-retest reliability (1 week) for the BAI = 0.75 (Beck, Epstein, Brown, & Steer, 1988)

Validity: The BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale (.51), and mildly correlated with the Hamilton Depression Rating Scale (.25) (Beck et al., 1988).

Company	Not at all	Mildly, but it didn’t bother me much	Moderately – it wasn’t pleasant at times	Severely – it bothered me a lot
All questions	0	0	0	0

Total Score: 0

The total score is calculated by finding the sum of the 21 items.

Score of 22-35 = moderate anxiety

Score of 36 and above = potential concerning levels of anxiety

References: Beck, A.T, Epstein, N., Brown, G., & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897.

Patients Printed Name

Patients Signature

Date & Time

We are NOT contracted with any Health Insurance Companies, and ONLY accept Attorney Liens, Med Pay through your Automobile Insurance, and Third Party Claims.

BALANCE SELF-TEST

1. Have you fallen in the past year?

Yes

2. Do you feel dizzy or off balance if you make a sudden change inYes ¨ No ¨ movement, such as- bending down or quickly turning?

Yes

3. Do you have hearing loss?

Yes

4. Do you require any assistance to walk, such as a person, a cane, a walker or a wheelchair?

Yes

5. Do you have balance problems when you are walking or climbing?

Yes

Patients Printed Name

Patients Signature

Date & Time

Contact us Today

NOTICE OF PRIVACY PRACTICE SUMMARY

Medical Lien Agreement

Pain Drawing

VEHICLE DRAWING

AUTO HISTORY

HEALTH QUESTIONNAIRE

Past Medical History

PRE-EXISTING CONDITIONS:

Social History:

Family Hisory:

Systematic Review:

General:

Skin:

Heent:

Respiratory:

Neck:

Neurological:

Cardio Vascular:

Psychological:

Gastrointestinal:

Allergies:

Hematological:

PATIENT INFORMATION:

CONTRACT FOR CONTROLLED SUBSTANCES

URINE TOXICOLOGY

INFORMED CONSENT FOR

CONTROLLED SUBSTANCE TREATMENT FOR PAIN

PATIENT LIEN

THIRD PARTY INSURANCE INFORMATION:

YOUR AUTOMOBILE INSURANCE INFORMATION:

ASSIGNMENT OF BENEFITS AGREEMENT

THIRD PARTY ASSIGNMENT OF BENEFITS AGREEMENT

Request for Patient Records

Section Break

SLIP & FALL HISTORY

BECK ANXIETY INVENTORY (BAI)

BALANCE SELF-TEST