Exit

1.

Thank you for considering our practice. We use one application for both bariatric & general surgery. If you are seeking nonbariatric (general) surgery with us, you can skip all the questions that are marked as bariatric patient-only. In all instances, once you hit DONE at the end of the questionnaire, your application will be submitted to us electronically and in a HIPAA compliant fashion. If you have not heard back from us within 1-2 business days, please contact us by phone or text at (805) 379-9796. If you prefer, a PDF of this questionnaire can be emailed or mailed to you.

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* 1. Your full name

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* 2. Your date of birth?

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* 3. Last 4 digits of your Social security number (for billing purposes only)

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* 4. Our office uses text service extensively for communicating with patients. It is NOT used for any marketing or non-office related issues. If you have a textable cellphone number, please share it with us.

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* 5. Email address(es) where you can receive personal private emails.

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* 6. Best telephone number(s) to reach you and leave private messages.

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* 7. Mailing address:

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* 8. Emergency contact information:

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* 9. Employer contact information

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* 10. What is your insurance? Please include as much information as possible including policy number.

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* 11. Secondary insurance information

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* 12. Primary care MD: Please include full name, address, phone and fax, and if known, email address

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* 13. Please provide the name, specialty, and complete contact information for your other doctors & healthcare providers

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* 14. How did you hear about University Bariatrics?

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* 15. If you were referred to us through a hospital website, advertising campaign, or doctor referral line: please indicate which one.

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* 16. Are you seeing us for bariatric (weight loss) surgery or for general surgery?

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* 17. FOR BARIATRIC SURGERY PATIENTS ONLY: How long have you been contemplating bariatric surgery?

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* 18. FOR BARIATRIC SURGERY PATIENTS ONLY: How have you researched about bariatric surgery?

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* 19. FOR BARIATRIC SURGERY PATIENTS ONLY: A pre-consultation information seminar attendance is highly encouraged -and sometimes mandatory- in bariatric surgery. Please indicate which one of the following applies to you?

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* 20. FOR BARIATRIC SURGERY PATIENTS ONLY: At what age did you first start dieting?

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* 21. FOR BARIATRIC SURGERY PATIENTS ONLY: Which of the following diets have you been on in the past. Please mark all that apply.

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* 22. FOR BARIATRIC SURGERY PATIENTS ONLY: What was the most successful weight loss program ever and how much weight did you lose. Please indicate approximate year or age.

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* 23. FOR BARIATRIC SURGERY PATIENTS ONLY: Are you a sweet eater? If so, please indicate type, amount, and freqency on a weekly basis

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* 24. FOR BARIATRIC SURGERY PATIENTS ONLY: Are you a carb eater? If so, please indicate type, amount, and freqency on a weekly basis

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* 25. FOR BARIATRIC SURGERY PATIENTS ONLY: Are you a fast-food eater? If so, please indicate type, amount, and freqency on a weekly basis

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* 26. FOR BARIATRIC SURGERY PATIENTS ONLY: On a typical day, how much soda or other non-alcoholic beverages do you consume daily?

  None 8 oz or less(one can) 16-24 oz (2-3 cans) 36-64 oz More than 64oz
Soda
Diet Soda
Juice
Crystal Lite or similar artificially sweetened drinks
Sports drinks (Gatorade)
Energy drinks (RedBull)
Coffee
Decafeinated coffee
Coffee drinks (eg latte, capuccino, machiatto, frappucino, etc)

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* 27. FOR BARIATRIC SURGERY PATIENTS ONLY: Which one of the following applies to you:

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* 28. FOR BARIATRIC SURGERY PATIENTS ONLY: Please indicate your height, weight, and BMI (if known)

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* 29. FOR BARIATRIC SURGERY PATIENTS ONLY: What are your primary goals and reasons to pursue weight loss surgery?

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* 30. Cardiac history: Please mark all that apply.

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* 31. Pulmonary History: Please mark all that apply.

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Please calculate your sleep score and document in the next question. 

Please calculate your sleep score and document in the next question. 

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* 32. What was your Epworth Sleepiness Score from chart above?

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* 33. Gastrointestinal history: Please mark all that apply.

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* 34. Endocrine history: Please mark all that apply.

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* 35. Hematological history: Please mark all that apply

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* 36. Urinary history: Please mark all that apply

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* 37. GYN history (women only): Please mark all that apply

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* 38. Musculoskeletal history: Please mark all that apply

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* 39. Neurological history: Please mark all that apply

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* 40. Psychological history: Please mark all that apply.

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* 41. Other history:

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* 42. FOR BARIATRIC SURGERY PATIENTS ONLY: Have you had previous weight loss surgery such as gastric bypass, adjustable bands, gastroplasty etc?

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* 43. FOR BARIATRIC SURGERY PATIENTS ONLY: If you have had previous weight loss surgery, please indicate which one(s).

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* 44. Other past medical or surgical history or hospitalizations not mentioned above. Please include approximate dates and write on SEPARATE lines for each event.

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* 45. If you have had general anesthesia before, i.e. have been put to complete sleep for a surgical procedure, please check the appropriate box.

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* 46. COMPLETE list of prescription medications.

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* 47. COMPLETE list of non-prescription, over-the-counter, or herbal medications and supplements.

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* 48. Drug or other chemical allergies

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* 49. Family history: Please mark all that apply.

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* 50. Current alcohol history:

  none Less than five drinks per week More than 6 drinks per week
Beer
Wine
Other liquor

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* 51. Current tobacco/nicotine history:

  No Yes
Cigarettes
Cigar
Chewable tobacco
E-cigarrettes
Pipe
Hookah or other modalities

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* 52. I currently use drugs including medical marijuana. 

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* 53. What is your current occupation

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* 54. Marital status

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* 55. What is your highest education level?

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* 56. FOR BARIATRIC SURGERY PATIENTS ONLY: Having a support system before and after surgery is vital to successful and safe outcomes. Whom do you think can help you in that regard?'"

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* 57. If possible, please upload a copy of the front of your driver license or another government issued ID card.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 58. If possible, please upload a copy of your insurance card front side. Supported formats are PDF, JPG,JPEG,GIF, PNG,DOC,DOCX

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 59. If possible, please upload a copy of the back of your primary insurance card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 60. If possible, please upload a copy of the front of your secondary insurance card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 61. If possible, please upload a copy of the back of your secondary insurance card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 62. Cancellation & NoShow Fee Last minute cancellations and no-shows are very disruptive to our practice as we do not overbook/doublebook appointment slots and we do allow generous blocks of times for each consult. It will also take away a potential consultation availability for other patients whom would have wanted that appointment slot but was not available to them. Therefore, effective October 18th 2022, patients who are a no-show to their appointment or cancel LESS than a day ahead and do not reschedule, may incur a $110 cancellation/no-show fee.

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* 63. ZOCDOC fee: For consultation appointments  made directly via the ZOCDOC website (and not via our practice's website's scheduling link), their booking fee ($110) may be passed on to you IF you do not cancel directly on ZOCDOC within the first 24 hours after booking ; OR if  you cancel at a later date and not reschedule your appointment;  OR if you are a no-show to your appointment.

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* 64. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that in spite of initial statements of full coverage, insurance companies have been known to alter course and claim the services are not “non-covered” or not considered “reasonable and necessary”. If your treatment or services are so determined by your insurance company, any non-covered balance, i.e. the difference between the billed amount and what the health plan pays us, may become your responsibility. By law, (AB72), your maximum liability will be the greater of what is allowed by your plan or 125% of Medicare payment for the same level of service.

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* 65. Your insurance company may rarely send reimbursement check(s) directly to you, the member, or whoever is the subscriber on your policy. In addition to the claims payment being mailed to you/subscriber, the check might be addressed to you/subscriber. In either case, you be required to endorse the back of the check with the member/insured signature, forward the signed check(s) together with a copy of the Explanation of Benefits (EOB) to our address. In this manner, we will be able to properly credit your account. Failure to remit the check(s) within 3 business days of receipt will result in your account going into default and therefore going to collections for the “full amount”. We do not accept the insurance check in payment installments.

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* 66. Our practice is in network with Medicare and almost all PPO plans including some of those in Covered California.

For In-network patients: the copay listed on your insurance card will be collected and you will be responsible for your part of the bill once the insurance has paid out.

For Cash/HMO/MediCal/GoldCoast/non-in-network patients: Depending on your visit type -including inPerson vs telehealth-: we collect a fixed amount at your visit and your insurance will be billed afterwards. You will not be receiving any future bills from us for those visits. Should you proceed with us for a cash pay surgery, the collected sum will be deducted from the final cash pay rate.

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* 67. If a surgery is planned, I understand that all items marked by an “X” on the surgery checklist must be completed prior to the preoperative appointment or my surgery date will be postponed. Upon review of my case by the entire team, or by the anesthesia service at a later date, I may be asked to furnish additional items not listed initially.

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* 68. For bariatric surgery patients: I understand that unless exempted by the University Bariatrics team, prior to my preoperative appointment, I am required to have met both the psychologist and the nutritionist. I have been given the list of approved providers and understand that cancelling or failing to show up to either venue, shows a lack of commitment and will postpone my surgery. Their fees are non-refundable regardless of cause. Insurance may or may not reimburse me for all or part of the fees. The financial aspects of the visits are purely between me and the providers that I am being referred to

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* 69. SUMMARY OF OUR HIPAA AND BILLING POLICIES (OUTLINED IN THE NEXT SEVERAL QUESTIONS)

1) WE ONLY SHARE YOUR PERSONAL HEALTH INFORMATION WITH OUR BILLING COMPANY, INSURANCE COMPANIES, AND OTHER DOCTOR OFFICES WHEN NECESSARY. NOBODY ELSE. A FULL VERSION OF THE HIPAA POLICY WILL BE GIVEN TO YOU IN OFFICE AT YOUR VISIT.

2) YOUR NAME & EMAIL WILL BE SHARED WITH AN OUTSIDE MARKETING COMPANY AND YOU WILL RECEIVE A MONTHLY E-BLAST WITH A VARIETY OF INFORMATION. YOU CAN OPT-OUT OF THOSE EMAILS UPON RECEIPT OF THE FIRST SUCH E-BLAST.

3) WE USE A HIPAA SECURE EMAIL SERVICE FOR MEDICAL COMMUNICATIONS. WE RECOMMEND PATIENTS TO DO THE SAME AS WELL BUT SOME OPT TO USE STANDARD EMAIL. IF YOU SHOULD CHOOSE TO DO SO, THAT WILL BE AT YOUR OWN RISK.

4) WE USE OFFICE TEXT EXTENSIVELY. IT IS NOT HIPAA SECURE AND WILL NOT BE USED TO COMMUNICATE MEDICALLY SENSITIVE INFORMATION. BUT AGAIN, SOME PATIENTS USE IT TO SEND US MEDICAL INFORMATION DUE TO ITS CONVENIENCE. IF YOU CHOOSE TO DO SO, THAT TOO WILL BE AT YOUR OWN RISK. SIMILARLY, WE DISCOURAGE SENDING TEXTS FOR MEDICALLY URGENT SITUATIONS BUT PATIENTS STILL DO AND THAT TOO IS AT YOUR OWN RISK.

5) WE ARE IN NETWORK WITH PRACTICALLY ALL LOCAL HEALTHPLANS, BUT WE CANNOT CONTROL INSURANCE COMAPANIES' DECISIONS AND WHEN SOMETHING THAT IS COVERED, IS LATER DENIED, YOU BECOME RESPONSIBLE FOR IT. WHEREAS WE GO THRU ALL THE USUAL APPEALS PROCESSES, YOU THE PATIENT ARE ULTIMATELY RESPONSIBLE FOR YOUR MEDICAL EXPENSES. IT IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE.

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* 70. We ask your permission to take your photograph for our own files. These will be used to better identify you at each visit and visually document your progress over time (for bariatric patients). They will be placed in your medical records and will NOT be shared with anyone or posted online.

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* 71. Our office offers patient communication by email. We will email correspondence to established patients who are 18 years or older, or the legal representative of established patients. We use email to communicate only about non-sensitive and non-urgent issues. All emails to or from you or about you to others will be made a part of your medical record. You have the same right of access to such emails as you do to the remainder of your medical record. Your email message may be forwarded to another office staff member as necessary for appropriate handling. We will not disclose your emails to researchers or others unless allowed by state or federal law. Email will also be used for communication with other physicians and non-MD personnel involved in your care. A HIPAA secure service such as SendIt is used. Communication by regular email has a number of risks, which include:
· Can be circulated, forwarded and stored in paper and electronic files
· Backup copies of emails may exist even if the file has been deleted
· Can be received by unintended recipients
· Can be intercepted, altered forwarded or used without authorization or detection
· Senders can easily type the wrong email address
· Can be used to introduce viruses into the computer system
I understand that nobody can guarantee the security and confidentiality of email communication. They cannot be responsible for messages that are not received or delivered due to technical failure, or for disclosure of confidential information not caused by intentional misconduct. I understand that I may also communicate with the doctor and/or office by telephone or during a scheduled appointment, and that email is not a substitute for care that may be provided during an office visit. Appointments should be made to discuss any new issues or any sensitive medical information. I give my consent for regular email communication to and from University Bariatrics MDs and staff as stipulated above with the understanding that it may involve sharing protected health information in a nonHIPAA fashion.

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* 72. Our office utilizes text service for much of its communication with patients. Some of the risks and privacy issues listed above pertain to text as well. The text service too may not be checked right away, including during office hours. Texting should not be used for urgent problems. By initializing here, you agree to be texted at the private cellphone number you have provided us with the understanding that personal health information can potentially be shared in a nonHIPAA fashion.

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* 73. We ask your permission to add you to our email contact list which will be shared with our affiliated outreach/marketing/website company for future outreach/informational purposes and that you can always opt-out of easily. NO medical information will ever be shared.

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* 74. You agree not to use email or text for urgent problems. If you have an urgent problem during regular business hours, please call our office or go to the nearest emergency room or urgent care facility. Emails and texts should not be time-sensitive. Urgent messages or needs should be relayed to us by using regular telephone communication.

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* 75. NOTICE OF PRIVACY PRACTICES ( STANDARD BOILERPLATE MATERIAL SPLIT INTO NEXT 5 QUESTIONS AS IT WOULD NOT FIT IN ONE QUESTION)
 
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USEDAND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR PLEDGE REGARDING YOUR MEDICAL INFORMATION
UNIVERSITY BARIATRICS is committed to protecting medical information about you. We create a record of the care and services you receive at UNIVERSITY BARIATRICS for use in your care and treatment.This Notice tells you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to make sure that your medical information is protected and give you this Notice describing our legal duties and privacy practices with respect to medical information about you; and follow the terms of the Notice that is currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU
The following sections describe different ways that we may use and disclose your medical information. For each category of uses or disclosures we will describe them and give some examples. Some information such as certain drug and alcohol information, HIV information and mental health information is entitled to special restrictions related to its use and disclosure. UNIVERSITY BARIATRICS  abides by all applicable state and federal laws related to the protection of this information. Not every use or disclosure will be listed. All of the ways weare permitted to use and disclose information, however, will fall within one of the following categories
For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, students, or other health system personnel who are involved in taking care of you in the health system. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to tell the hospital’s food service if you have diabetes so that we can arrange for appropriate meals. We may also share medical information about you with other UNIVERSITY BARIATRICS  personnel or non-UNIVERSITY BARIATRICS  providers, agencies or facilities in order to provide or coordinate the different things you need, such as prescriptions, lab workand x-rays. We also may disclose medical information about you to people outside UNIVERSITY BARIATRICS who may be involved in your continuing medical care after you leave UNIVERSITY BARIATRICS such as other health care providers, transport companies, community agencies and family members.
For Payment. We may use and disclose medical information about you so that the treatment and services you receive at UNIVERSITY BARIATRICS  or from other entities, such as an ambulance company, may be billed to and payment may be collected from you, an insurance company or a third party. For example, we may need to give information to your health plan about surgery you received via UNIVERSITY BARIATRICS  so your health plan will pay us or reimburse you for the surgery. We may also tell your health plan about a proposed treatment to determine whether your plan will cover the treatment.

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* 76. For Health Care Operations. We may use and disclose medical information about you for UNIVERSITY BARIATRICS  operations. These uses and disclosures are made for quality of care and medical staff activities, UNIVERSITY BARIATRICS  health sciences education, and other teaching programs. Your medical information may also be used or disclosed to comply with law and regulation, for contractual obligations, patients’ claims, grievances or lawsuits, health care contracting, legal services, business planning and development, business management and administration, the sale of all or part of UNIVERSITY BARIATRICS  to another entity, underwriting and other insurance activities and to operate the health system. For example, we may review medical information to find ways to improve treatment and services to our patients. We may also disclose information to doctors, nurses, technicians, medical and other students, and  other health system personnel for performance improvement and educational purposes.
Appointment Reminders. We may contact you to remind you that you have an appointment at UNIVERSITY BARIATRICS .
Treatment Alternatives. We may tell you about or recommend possible treatment options or alternatives that may be of interest to you
Health-Related Benefits and Services. We may contact you about benefits or services that we provide.
Fundraising Activities. We may contact you to provide information about UNIVERSITY BARIATRICS sponsored activities, including fundraising programs and events. We would only use contact information, such as your name, address and phone number and the dates you received treatment or services at UNIVERSITY BARIATRICS.
News Gathering Activities. A member of your health care team may contact you or one of your family members to discuss whether or not you want to participate in a media or news story. News reporters often seek interviews with patients injured in accidents or experiencing particular medical conditions or procedures. For example, a reporter working on a story about a new cancer therapy may ask whether any of the patients undergoing that therapy might be willing to be interviewed.

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* 77. Hospital Directory. If you are hospitalized, we may include certain limited information about you in the hospital directory. This is so your family, friends and clergy can visit you in the hospital and generally know how you are doing. This information may include your name, location in the hospital, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The directory information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to members of the clergy, such as ministers or rabbis, even if they don’t ask for you by name. You may restrict or prohibit the use or disclosure of this information by notifying the Director of Patient Access Services.
Individuals Involved in Your Care or Payment for Your Care. We may release medical information to anyone involved in your medical care, e.g., a friend, family member, personal representative, or any individual you identify. We may also give information to someone who helps pay for your care. We may also tell your family or friends about your general condition and that you’re inpatient.
Disaster Relief Efforts. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research. All research projects conducted must be approved through a special review process to protect patient safety, welfare and confidentiality. Your medical information may be important to further research efforts and the development of new knowledge. We may use and disclose medical information about our patients for research purposes, subject to the confidentiality provisions of state and federal law. On occasion, researchers contact patients regarding their interest in participating in certain research studies. Enrollment in those studies can only occur after you have been informed about the study, had an opportunity to ask questions, and indicated your willingness to participate by signing a consent form. When approved through a special review process, other studies may be performed using your medical information without requiring your consent. These studies will not affect your treatment or welfare, and your medical information will continue to be protected. For example, a research study may involve a chart review to compare the outcomes of patients who received different types of treatment.
As Required By Law. We will disclose medical information about you when required to do so by federal or state law.
To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent or lessen a serious and imminent threat to your health and safety or the health and safety of the public or another person. Any disclosure would be to someone able to help stop or reduce the threat.
Organ and Tissue Donation. If you are an organ donor, we may release medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation
Military and Veterans. If you are or were a member of the armed forces, we may release medical information about you to military command authorities as authorized or required by law. We may also release medical information about foreign military personnel to the appropriate military authority as authorized or required by law.
Workers' Compensation. We may use or disclose medical information about you for Workers' Compensation or similar programs as authorized or required by law. These programs provide benefits for work-related injuries or illness.

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* 78. Public Health Disclosures. We may disclose medical information about you for public health purposes. These purposes generally include the following:
• preventing or controlling disease (such as cancer and tuberculosis), injury or disability;
• reporting vital events such as births and deaths;
• reporting child abuse or neglect;
• reporting adverse events or surveillance related to food, medications or defects or problems with products;
• notifying persons of recalls, repairs or replacements of products they may be using;
• notifying a person who may have been exposed to a disease or may be at risk of contracting or spreading a disease or condition;
• notifying the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence and make this disclosure as authorized or required by law.
Health Oversight Activities. We may disclose medical information to governmental, licensing, auditing, and accrediting agencies as authorized or required by law.
Legal Proceedings. We may disclose medical information to courts, attorneys and court employees in the course of conservatorship and certain other judicial or administrative proceedings.
Lawsuits and Other Legal Actions. In connection with lawsuits or other legal proceedings, we may disclose medical information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons or other lawful process.
Law Enforcement. If asked to do so by law enforcement, and as authorized or required by law, we may release medical information:
• To identify or locate a suspect, fugitive, material witness, or missing person;
•About a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
• About a death suspected to be the result of criminal conduct;
• About criminal conduct at UNIVERSITY BARIATRICS ; and
• In case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. In most circumstances, we may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We may also disclose medical information about patients of UNIVERSITY BARIATRICS  to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities. As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.
Protective Services for the President and Others. As authorized or required by law, we may disclose medical information about you to authorized federal officials so they may conduct special investigations or provide protection to the President, other authorized persons or foreign heads of state.
Inmates. If you are an inmate of a correctional institution or under the custody of law enforcement officials, we may release medical information about you to the correctional institution as authorized or required by law.
YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU
Your medical information is the property of UNIVERSITY BARIATRICS . With certain exceptions, you have the right to inspect and/or receive a copy of your medical information. To inspect and/or to receive a copy of your medical information, you must submit your request in writing to us. In addition, we may deny your request if you ask us to provide you with information that was not created by UNIVERSITY BARIATRICS.

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* 79. Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information to a family member about a surgery you had. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, only to you and your spouse. We are not required to agree to your request
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you only at home or only by mail.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.
We reserve the right to change UNIVERSITY BARIATRICS ’s privacy practices and this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. I have reviewed the above information and acknowledge receipt of this information

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* 80. New Law Requires Notice to Patients About Open Payments Database

Pursuant to Assembly Bill (AB) 1278, physicians are required to provide a notice to their patients regarding the Open Payments database (https://openpaymentsdata.cms.gov/), which is managed by the U.S. Centers for Medicare & Medicaid Services, or CMS. Specifically, this new law requires physicians to do the following beginning January 1, 2023:At the initial office visit with their patient, a physician must provide either a written or electronic notice of the  Database that includes the following text: “The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.” If the physician uses an electronic records system, they must include a record of this notice in the patient’s records.



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* 81. This application has been filled out by myself or with the help of someone else under my guidance. In either case, by writing my name below, I attest that all the information is accurate to the best of my abilities.The undersigned agrees, whether he/she signs as agent or as patient, that in consideration for the service to be rendered to the patient, he/she obligates himself/herself to pay any and all unpaid balances. Should the account be referred to collection, she/he understands and agrees to incur any/all additional expenses and attorney’s fees. The undersigned certifies that he/she has read the foregoing, and is the patient, patient’s legal representative, or is duly authorized by the patient to execute the above and accept its terms.

I have read & understood all of the requirements above and all of my questions related to the above have been answered. I also understand that the return of this agreement is required before the University Bariatrics program can move forward with anything related to my care.

If you are helping the patient fill out this form, please include your name and relationship as well.

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