New Patient Form

  • REQUIRED PATIENT INFORMATION FOR BILLING

    • Date Format: MM slash DD slash YYYY
  • PRIMARY INSURANCE INFORMATION

    If Primary Insured IS NOT the Patient, List Spouse, Parent or Other Information of Primary Insured below
    • Date Format: MM slash DD slash YYYY
    • Please include the social security number and date of birth of the primary insured for your insurance to be billed.
  • SECONDARY INSURANCE INFORMATION

    If Secondary Insured IS NOT the Patient, List Spouse, Parent or Other Information of Primary Insured below
    • Date Format: MM slash DD slash YYYY
    • Please include the social security number and date of birth of the primary insured for your insurance to be billed.
  • PAYMENT POLICIES

    You are responsible for anything your insurance does not cover. All Co-Pays are due and payable at each visit. These fees may apply: (please initial tick all boxes and sign the agreement)
    If you are a private pay patient without insurance, all charges are due at the time of the visit. We do not send statements to private pay patients.
  • PRESCRIPTION POLICY

    Please do not wait until your last pill to coll for a refill. There is a 48-hour turnaround for prescription refills. If you have not seen the Physician In six months, the prescription will be denied. Assignment of benefits ore payable to the doctors
  • PLEASE SIGN AND DATE THIS DOCUMENT SHOWING THAT YOU HAVE READ AND UNDERSTAND OUR POLICIES.
  • SAYANA MEDICAL & WELLNESS CENTER

    Patient Privacy Practices Form
  • Date Format: MM slash DD slash YYYY
  • Information Release: In the event when a specialist referral is necessary as a result of Dr. Sayana's assessment, I also authorize you to release my medical records and insurance information to the referred doctor/hospital/doctor's office for the continuation of medical care, advice, treatment provided to me. For medical records requested from other parties not mentioned in this paragraph, I will provide a separate Medical Record Release Form authorizing such release.

    Notice of Privacy Practices / Patient Acknowledgement:

    THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    This notice of Privacy Practices (the "notice" ) describes the privacy practices of the Sayana Medical Spa & Wellness Center. lnc. (the " Center") and applies to all health professionals, employees, staff, and other personnel who are involved in your care. In order to provide you with quality care and to comply with certain state and federal legal requirements. we create a record of the services we provide to you. This Notice applies to all records of your care generated by the Center, whether made by staff or your doctor and describes the way 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 medical information. We are required by law to:

    • Make sure that medical information that identifies you is kept private (with certain exceptions);
    • Give you this notice of its legal duties and privacy practices concerning medical information about you;
    • follow the terms of the notice that is currently in effect.

    If you have any questions about this notice, please contact our Privacy Officer (Dr. Shilpa Sayana) at the address and telephone number listed above.

    HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION

    The following categories describe different ways that we may use and disclose protected medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

    Disclosure At Your Request. We may disclose medical information when requested by you. This disclosure may require that you sign a written authorization.

    For Treatment. We may use or disclose health information about you to provide you with medical treatment. We may disclose health information about you to doctors, nurses therapists, technicians, case managers, or other Center personnel who are involved in taking care of you at the Center. We may also disclose health information about you to people outside the Center who may be involved in your medical care after you leave the Center, to assist them in treating you.

    For Payment Purposes. We may use or disclose protected health information so that we, or other health care providers, may bill and collect for the services we provide to you. For example, we may disclose information from your medical records to your health insurance company to obtain pre-authorization for treatment or submit a claim for payment. 

     

    For Healthcare Operations. We may use or disclose protected health information for certain health care operations that are necessary to run our practice and ensure that our patients receive quality care. For example, we may use the information from your medical records to review the performance or qualifications of physicians and staff; train staff; or make business decisions affecting our practice.

    As Required By Law. We will disclose your health information when required to do so by federal, state or local law.

    To Avert a Serious Threat to Health or Safety In certain circumstances, we may be required to disclose medical information to avert a serious threat to your health and safety or the health and safety of another person or as required by law enforcement. Any disclosure would only be to someone able to help prevent the threat.

    Health-Related Benefits and Services and Reminders. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

    For Research. We may use or disclose protected health information for research if approved by an institutional review board or a privacy board and appropriate steps have been taken to protect information.

    To Individuals or Family Members Involved In Your Care Or Payment For Care. Unless there is a specific written request from you to the contrary. we may disclose protected health information to a member of your family. relative, dose friend, or other person identified by you who is involved in. our health care or the payment for your health care. We will limit the disclosure to the protected health information relevant to that person's involvement in your health care or payment. In addition, we may disclose medical information about you to a public or private entity assisting in disaster relief:

    SPECIAL SITUATIONS Workers' Compensation.

    We may disclose protected health information as authorization by workers' compensation laws and other similar legally-established programs.

    Military and Veterans. If you are a member of the armed forces. we may disclose health information about you as required by military authorities. We may also disclose health information about foreign military personnel to the appropriate for ign military authority.

    Business Associates. There are some services provided in our Center through contacts with business associates. Examples include medical directors, outside attorneys, and a copy service we u e when making copies of your health record. When these services are contracted, we may disclose your health information so that they can perform the job we've asked them 10 do and bill you or your third-pai1y payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

    Organ donation. We may use or disclose protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaver organs or tissue.

    Coroners. Medical Examiners and Funeral Directors. We may disclose medical in format io n to a coroner or medical examiner. This may be necessary to identify a deceased person or determine the cause of death. We may also disclose medical information to funeral directors as necessary to carry out their duties.

    Correctional Institution. Should you be an inmate of a correctional institution, we may disclose to the institution or its agents' health information necessary for your health and the health and safety of others.

    Reporting. Federal and state laws may require or permit the Center to disclose certain health information related to the following: Public Health Risks. We may disclose health information about you for public health purposes, including:

    • Prevention or control of disease, injury or disability
    • Reporting births and deaths;
    • Reporting child abuse or neglect;
    • Reporting reactions to medications or problems with products; Notifying people of recalls of products; Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;
    • Notifying the appropriate government authority if we believe a resident has been the victim of abuse, neglect or domestic violence.

    We will only make this disclosure if you agree or when required or authorized by law.

    Public Health Risks.

    We may disclose health information about you for public health purposes, including

    • Prevention or control of disease, injury or disability Reporting births and deaths;
    • Reporting child abuse or neglect;
    • Reporting reactions to medications or problems with products;
    • Notifying people of recalls of products; Notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease;
    • Notifying the appropriate government authority if we believe a resident has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

    Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

    Judicial and Administrative Proceedings: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a corn1 or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or another lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

    Reporting Abuse, Neglect or Domestic Violence: Notifying the appropriate government agency if we believe a resident has been the victim of abuse, neglect or domestic violence.

    Communicable Disease: We are required to disclose protected health information concerning certain communicable diseases to the appropriate government agency. To the extent authorized by law, we may also disclose protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

    Law Enforcement. We may disclose health information when requested by a law enforcement official:

    • In response to a court order, subpoena, warrant, summons or similar process;
    • To identify or locate a suspect, fugitive, material witness, or missing person;
    • About you, the victim of a crime if, under certain limited circumstances, we are unable to obtain your agreement;
    • About a death we believe may be the result of criminal conduct;
    • About criminal conduct at the Center; and
    • ln emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

    National Security and Intelligence Activities. We may disclose health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

    Marketing. Your written authorization ("Your Marketing Authorization") must be obtained prior to using your personal health information to send you any marketing materials. However, we may communicate with you about our products or services relating to our treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization. W are also permitted to give you a promotional gift of nominal value if we so choose, without obtaining your authorization. Also. from time to time, we receive letters from patients their family members and friends describing the experience and care they received from us. Where possible, we share these letters with our employees and patients. Prior to sharing your letter, we will remove your name and other identifying information from the letter to protect your privacy.

    Special Categories of Information. In some circumstances, your health information may be subject to restrictions that may limit or preclude some uses or disclosures described in this Notice. For example, there are certain restrictions on the use or disclosure of certain categories of information, such as tests for HIV or treatment for alcohol and drug abuse, or treatment for mental health conditions.

    YOUR RIGHTS CONCERNING YOUR PROTECTED HEALTH INFORMATION

    Right to Inspect and Copy Records. You have the right to inspect and receive copies of your medical information that is in our records including treatment and billing records. To inspect and receive a copy of your medical information, you must submit your request in writing to the address set forth below:

    Sayana Medical Spa & Wellness Center, Inc. 11724 Ventura Blvd, Suite A Studio City, California 91604

    We will charge you a reasonable cost-based fee for providing the records. We may deny your request under limited circumstances (for example. information prepared for legal proceedings: or if disclosure may result in substantial harm to you or others).

    Right to Request Additional Restrictions. You may request additional restrictions on the use or disclosw·e of your protected health information for treatment, payment or health care operations. We are not required to agree to a requested restriction. If we agree to a restriction, we will comply with the restriction unless an emergency or the law prevents us from complying with the restriction, or until the restriction is terminated To request restrictions, you must put your request in writing to Dr. Sayana at the address set forth in this Notice. For your request. you must tell us: (i) What information you want to limit (ii) Whether you want to limit the Center's use. disclosure or both: (iii) To whom you want the limit to apply, for example. disclosures to your spouse.

    Right to Receive Communications by Alternative Means. We normally contact you by telephone or mail at your home address. You may request that we contact you by some other method or at some other location. To request confidential communications, you must put your request .in writing to our Privacy Officer at the address set forth in this Notice. We will accommodate reasonable requests. We may require that you explain how payment will be handled if an alternative means of communication is used.

    Right to Amend Your Personal Health Information. If you feel that your personal health information is incorrect or incomplete. you may ask us to amend the information.

    You have the right to request an amendment for as long as we keep your medical information. All requests for amendment must be made in writing and must be submitted to our Privacy Officer. In addition, you must provide a reason that supports your request.

    We may deny your request for an amendment if the information was not created by us unless the person or entity that created the medical information is no longer available to make the amendment; if the information is not part of the medical information kept by us, is not part of the medical information about you that you would be permitted to inspect and copy; or the information is accurate and complete. if we deny your request for amendment, you have the right to submit a written statement or addendum, with a description not to exceed 250 words, >with respect to any item or statement in your record you believe is incomplete or incorrect.

    We will attach it to your records and include it whenever we make a disclosure of the item or statement you believe to be incomplete or incorrect.

    Right to an Accounting of Certain Disclosures. You may receive an accounting of certain disclosures we have made of our protected health information, other than for disclosures for treatment, a ment, or health care operations; to family members or others involved in your health care for payment; for notification purposes; or pursuant to your written authorization n. To request this list of accounting of disclosures, you must make a written request to our Privacy Officer at the address on this Notice. Your request must state a time period that may not be longer than six (6) years and may not include a date before April 14, 2003. You may receive the first accounting within a 12-month period free of charge. We will charge a reasonable cost-based fee for all subsequent requests during that 12-month period. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time before any costs are incurred. In addition, we will notify you as required by law if your medical information is unlawfully accessed or disclosed or accessed by an unauthorized person or if there is a breach of our security system.

    Right to a Copy of This Notice. You have the right to obtain a paper copy of this Notice upon request. You have this right even if you have agreed to receive the Notice electronically.

    OTHER USES OF HEALTH INFORMATION

    Other uses and disclosures of health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you. you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

    CHANGES TO THIS NOTICE

    We reserve the right to change the terms of our Notice of Privacy Practices at any time and to make the new Notice provisions effective for all protected health information that we maintain. If we materially change our privacy practices we will prepare a new Notice of Privacy Practices, which shall be effective for all protected health information that we maintain. We will post a copy of this client Notice in our reception area and on our website. You may obtain a copy of the current Notice in our reception area, or by contacting our Privacy Officer.

    TO FILE A COMPLAINT

    If you believe your privacy rights have been violated, you may send a written complaint to:

    Sayana Medical Spa & Wellness Center, Inc. 11724 Ventura Blvd, Suite A Studio City, California 91604

    You also may file a written complaint with the U.S. Department of Health and Human Services, Office of Civil Rights, Hubert H. Humphrey Building, 200 Independence /\venue S.W., Room 509, HHH Building, Washington. D.C. 20201. You will not be penalized or retaliated against for filing a complaint.

    NOTICE OF PRIVACY PRACTICES:

    Acknowledgment of Review I acknowledge reading and understanding the Notice of Privacy Practices. 1 understand that I can obtain this practice's current Notice of Privacy Practices on request. 

  • Name and capacity to sign if other than the client (i.e., the parent or guardian)