PATIENT FORMS

Saddleback Medical Group has provided the highest quality of healthcare to adults, children, and teens in the Laguna Hills, California area for more than 15 years. We look forward to your first visit. Call to schedule your preferred appointment. Once your appointment is set, please download and complete our New Patient Registration Forms. When you arrive for your first visit, please check in with our receptionist and provide your completed forms. As an alternative, you may complete your patient forms online.

New Patient online forms:

A desk with some office supplies and a laptop

Downloadable forms:

Dermatology

Post Op Wound Care (Dermatology).pdf
Post Op Skin Rejuvenation (Dermatology).pdf
Dry Sensitive Skin (Dermatology).pdf
Actinic Keratoses (Dermatology).pdf
Acne (Dermatology).pdf

1. FAILED APPOINTMENT CHARGE — Due to increasing pressures on physician schedules, it is now necessary to institute a policy for late appointment cancellations or "no shows." We reserve the right to charge for each failed appointment not cancelled at least 24 hours before the scheduled appointment time. The appointment must be cancelled within one (1) business day, Monday through Friday only. This charge is not covered by your insurance.
Our charges are as follows: Office Visit $45.00 - $90.00
Dermatology Procedure $150.00

2. FORM COMPLETION CHARGE — There may be a charge for each form a patient may request us to complete such as: Assisted living forms, DMV forms, health assessments, letter(s) to third parties, etc. If forms or reports are lengthy, charges may be higher depending on the amount of time spent on complete. This charge is not covered by your insurance.
Our changes are as follows: $25.00 - $50.00

3. RETURNED CHECK CHARGE — All accounts with checks returned from the bank for any reason will be assessed $25.00 per returned check. This charge is not covered by your insurance.

4. CO-PAYMENTS — Patients are required to pay their co-payments at the time of the office visit. This is a contractual obligation between you and your health plan. Failure to pay your co-payment could result in denial of service(s). We accept cash, checks, debit cards, VISA®, and MasterCard®.

5. MEDICAL RECORDS — There is a charge for copying your medical records and transferring them to another physician. The charge starts at $25.00 plus any applicable postage fees. Our Medical Records Department personnel will assist you with the processing of your request.

6. I authorize Saddleback Medical Group Inc. through its vendors or directly to contact me by SMS text message to serve me better. Saddleback Medical Group Inc. will send me text messages through Saddleback Medical Group Inc.’s members outreach partners to help me or my family members provide feedback, remind me of appointments, and remain better connected to the practice. I understand that message/data rates may apply to messages sent through Saddleback Medical Group Inc. to my cell phone. I know that I am under no obligation to authorize Saddleback Medical Group Inc. to send me text messages as part of this program. I may opt-out of receiving these communications from Saddleback Medical Group Inc. at any time by contacting your providers office.

By signing this sheet, I acknowledge and agree to the above office policies.

Patient Name (please print):(Required)

First Last

Signature:(Required)

Date:(Required)

Is there a family member with whom we may discuss your medical history? If so, please list:

Gastroenterology

www.saddlebackgi.com

Please note: It may take a few minutes to load the forms if you are using a dial-up Internet Connection. If you are unable to view the forms, you may need to download Adobe Acrobat for free by clicking on the Adobe icon.

Disclaimer: Filling out and submitting any new patient online forms does not establish a physician-patient relationship nor does it constitute any individual as an established patient of Saddleback Medical Group, Inc. or any physician therein.

Thank you have and have a great day !

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.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical and dental records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse Protected Health Information (PHI).

This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information
Your Protected Health Information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the practice, and any other use required by law.

Treatment: We will use and disclose your Protected Health Information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the health care professional has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, and conducting or arranging for other business activities. We may use or disclose, as needed, your protected health information to support the business activities of this practice. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment. We may call your home and leave a message (either on an answering machine or with the person answering the phone) to remind you of an upcoming appointment, the need to schedule a new appointment or to call our office. We may also mail a postcard reminder to your home address. If you would prefer that we call or contact you at another telephone number or location, please let us know.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of HIPAA.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights
The Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in you care or for notification purposes described in this Notice of Privacy Practices. Your request must state the specific restriction and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction you may request. If your physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice alternatively (i.e. electronically).
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this Notice and will inform you of any changes. You then have the right to object or withdraw as provided in this Notice.

Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer of your complaint at our office and main telephone number. We will not retaliate against you for filing a complaint.

This Notice was published and becomes effective on/or before 8/17/2020 10:26 AM.

Saddleback Medical Group
24221 Calle de la Louisa
Floors 2, 3, 4
Laguna Hills, California 92653

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