Ashay A. Kale, MD Soheil Motamed, MD Ricardo Molina, MD
Joshua Van Gompel, DPM Co V. Banh, MD Gabriel Van Gompel, DPM
Lauren Stark, PA-C Victoria Tung, PA-C Keith Bersch, PA-C, Ava Novotny, PA-C,
Orthopaedic Surgery
Arthroscopy & Sports Medicine
Shoulder & Elbow Surgery
Joint Replacement
Podiatry: Foot & Ankle Surgery
Physical Medicine & Rehabilitation
Interventional Spine Care
The following information is essential for us to bill your Insurance Company and to comply with HIPPA
regulations. We are required to ask for the information listed below.
1) PATIENT REGISTRATION:
CHART #
WHO MAY WE THANK FOR YOUR REFFERAL?
YELLOW PAGES
FIRST NAME
FRIEND
MS.
MIDDLE
LAST
MARITAL STATUS:
MRS.
DATE:
PRIMARY CARE PHYSICIAN:
WEBSITE
CIRCLE ONE
MR.
DR:
REFERRING PHYSICIAN:
MISS
STREET ADDRESS
WORK PHONE NUMBER
SOCIAL SECURITY #
□SINGLE □MARRIED □DIVORCED
□WIDOW
CITY
EXT
CELL PHONE NUMBER
DRIVER’S LICENSE
AGE
□ MALE
□FEMALE
STATE
ZIP
HOME PHONE NUMBER
E-MAIL ADDRESS
HOW WOULD YOU LIKE TO BE REMINDED OF YOUR APPOINTMENT
□ PHONE □E-MAIL □TEXT
PHONE CARRIER:
BIRTHDATE
IF BY TEXT, PLEASE PROVIDE CELL
DATE OF INJURY
MAY WE LEAVE A MESSAGE: □HOME ANSWERING MACHINE
□WORK ANSWERING MACHINE
□ANYONE ANSWERING HOME
PHONE
□ANYONE ANSWERING WORK PHONE □ NO ONE
RACE: □WHITE □AFRICAN AMERICAN □HISPANIC □AMERICAN INDIAN □OTHER:
LANGUAGE PREFERRED:
ETHNICITY: □NOT HISPANIC OR LATINO □HISPANIC OR LATINO IF CHECKED SPECIFY:
EMPLOYER NAME OR NAME OF SCHOOL
NAME OF SKILLED NURSING FACILITY
2) EMERGENCY CONTACT
NAME OF PERSON
RELATIONSHIP
HOME/CELL PHONE
WORK PHONE
3) WORK RELATED INJURIES
NAME OF COMPENSATION INSURANCE CARRIER
ADJUSTER AND PHONE NUMBER
CARRIER’S ADDRESS
NAME OF EMPLOYER(AT THE TIME OF INJURY)
ADJUSTER FAX NUMBER
ADDRESS
DATE OF INJURY
AUTHORIZATION GIVEN BY
NURSE CASE MANAGER
PHONE NUMBER
INDUSTRIAL CLAIM/CASE NUMBER
□ CONSULT ONLY
□ CONSULT AND TREAT
□ TRANSFER CARE
SIGNATURE________________________________________DATE______________________
Ashay A. Kale, MD Soheil Motamed, MD Ricardo Molina, MD
Joshua Van Gompel, DPM Co V. Banh, MD Gabriel Van Gompel, DPM
Lauren Stark, PA-C Victoria Tung, PA-C Keith Bersch, PA-C Ava Novotny, PA-C
Orthopaedic Surgery
Arthroscopy & Sports Medicine
Shoulder & Elbow Surgery
Joint Replacement
Podiatry: Foot & Ankle Surgery
Physical Medicine & Rehabilitation
Interventional Spine Care
Medical History and Information. Pharmacy Name, City and Street________________
What name do you prefer to be called ______________________________Height________ Weight______ Left or Right Handed: L / R
Allergies to medications? NO __ If Yes, Penicillin Sulfa Novocain Codeine Other___________________________________________
What Happens _________________________________________________________________________________________________________
Do you have allergies to foods/other(tape, dye)? NO/ If Yes please describe _________________________________________________________
Do you have or have you had any of the following, please circle or write in specific conditions
Yes No
Yes No
Heart Disease
Shortness of breath
Diabetes
Renal failure/insufficiency
Heart attack/MI
COPD/Emphysema
Pacemaker/AICD
Asthma
Kidney Stones
Chest pain
Sleep Apnea
Bladder problems
Irregular Heart Beat
Tuberculosis/TB
Prostate problems
Valve problem or murmur
Cancer
Thyroid problems
High Blood pressure
Seizure
Easy bruising or bleeding
Stroke
Arthritis
Low platelet count
Osteoarthritis, rheumatoid, psoriatic
High Cholesterol
Blood Clots
Pulmonary Embolism
Stomach ulcer or Reflux
Back problems
Chronic Pain
Constipation
Autoimmune diseases
Lupus, Reynaud’s
Diarrhea
Mental Health History
HIV or AIDS
Chron’s Disease
Muscular Dystrophy
Skin Disorders
Ulcerative Colitis
Multiple Sclerosis
Myasthenia
Gravis
Fevers/Chills
Diverticulosis
Numbness
hands
or
feet
Recent Weight loss/gain
Hepatitis
Dizziness
Current Sore Throat
Jaundice
Weakness
Recent changes in vision
Answer the following questions as the apply to you:
Yes No
Recent illness, cold, cough or fever within the 2 weeks…………………. Is there a possibility you are pregnant? …………………………………. . Last menstrual period______
Do you have a history of smoking? ……………………………………….. Packs/day____ #of years____ Date Quit______
Do you drink alcoholic beverages? ……………………………………….. How often_______ How much_________
Do you have a history of substance abuse or addiction?………………... Have taken oral or injectable steroids? …………………………………… Are you involved in litigation for this injury? ……………………………… Surgeries or Hospitalizations: None
If YES please list:
Yes
No
If the patient is a child
Please answer the following:
Yes No
Child was born premature ……………………………………... Birth defects or developmental delays....…………………….. History of frequent fractures …………………………………… Immunization problems or delays
in immunization schedule ……………………………………… Health Conditions of immediate family members:
…………………………………………………………………………
Current Medications: None
If YES please list Name and Dosages
Please use reverse side if more room is needed
Patient (or Guardian) Signature__________________________________________
Date_____/_____/_____
Ashay A. Kale, MD Soheil Motamed, MD Ricardo Molina, MD
Joshua Van Gompel, DPM Co V. Banh, MD Gabriel Van Gompel, DPM
Lauren Stark, PA-C Victoria Tung, PA-C Keith Bersch, PA-C Ava Novotny, PA-C
Orthopaedic Surgery
Arthroscopy & Sports Medicine
Shoulder & Elbow Surgery
Joint Replacement
Podiatry: Foot & Ankle Surgery
Physical Medicine & Rehabilitation
Interventional Spine Care
Patient Name ________________________________________________________ Date_________________
TO OUR PATIENT OR LEGAL REPRESENTATIVE PLEASE READ AND SIGN:
IF PATIENT IS A MINOR: Please fill out the following CONSENT FOR MEDICAL TREATMENT
I, _________________________________(Print name), am the parent/legal guardian of _________________________(print name of
minor), currently a minor, whose date of birth is _____/______/_____. I authorize Mission Peak Orthopaedics to provide medical care to my
son/daughter, including, but not limited to, diagnostic examinations (including radiological and laboratory testing).
___________________________________________
SIGNATURE OF CUSTODIAL PARENT/LEGAL GUARDIAN
PLEASE BE ADVISED THAT WE BILL YOUR INSURANCE ON YOUR BEHALF. HOWEVER,
IT IS THE PATIENT’S RESPONSIBILITY TO KNOW AND UNDERSTAND POLICIES AND BENEFITS OF THEIR OWN
INSURANCE PLAN.
ASSIGNMENT OF BENEFITS-FINANCIAL AGREEMENT
I hereby give authorization for payment of insurance benefits to be made directly to Mission Peak Orthopaedic Medical Group for services
rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of
default, I agree to pay all costs of collection, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all
necessary information to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.
HIPAA COMPLIANCE
As mandated by the Federal Government and office of Civil Rights, Mission Peak Orthopaedic Medical Group is required to follow
the HIPAA Compliance Act to ensure patient confidentiality. I understand that as part of my healthcare, Mission Peak Orthopaedic
Medical Group maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any
plans for future care treatment.
I understand that this information serves as a 1) basis for planning my care and treatment; 2) means of communication amount the
many healthcare professionals who contribute to my care; 3) source of information for applying my diagnosis and surgical information to my
bill; 4) means by which a third-part can verify that services billed were actually provided: 5) a tool for routine healthcare operations such as
assessing care quality and reviewing the competence of healthcare professionals.
I understand that I have the right: 1) to object to the use of my health information for directory purposes: 2) to request restrictions as to how
my health information may be used or disclosed to carry out treatment, payment or healthcare operation—and that the organization is not
required to agree to the restrictions requested: 3) to revoke this consent in writing, except to the extent that the organization has already taken
action in reliance thereon.
I REQUEST THE FOLLOWING RESTRICTIONS TO THE USE OR DISCLOSURE OF MY HEALTH INFORMATION:
Detailed message regarding test results can be left on my answering machine:
□ Yes □ No
MEDICAL INFORMATION CAN BE DISCUSSED WITH: □ PATIENT ONLY □ FAMILY MEMBER OR FRIEND___________
□ PHYSICIAN □ OTHER____________________ □ OTHER RESTRICTIONS_____________________________
_____________________________________________
Signature of Patient or Legal Representative
If you are a Medicare patient, please read and sign.
MEDICARE AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN
I REQUEST THAT PAYMENT OF AUTHORIZED Medicare benefits be made or on my behalf to Mission Peak Orthopaedic
Medical Group for any services rendered by physician/supplier. I authorize any holder of medical information about me to release to the
Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related
services.
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim.
If item 9 of the HCFA-1500 claim form is complete, my signature authorizes releasing information to the insurer of the agency shown. In
Medicare assigned cases, the physician/supplier agrees to accept the charge determination of Medicare. The patient is responsible only for the
deductible, co-insurance, and non-covered services. Co-insurance and deductibles are based upon the charge determination made by the
Medicare carrier.
_____________________________________________
Signature of Patient or Legal Representative
Ashay A. Kale, MD Soheil Motamed, MD Ricardo Molina, MD
Joshua Van Gompel, DPM Co V. Banh, MD Gabriel Van Gompel, DPM
Lauren Stark, PA-C Victoria Tung, PA-C Keith Bersch, PA-C Ava Novotny, PA-C
Orthopaedic Surgery
Arthroscopy & Sports Medicine
Shoulder & Elbow Surgery
Joint Replacement
Podiatry: Foot & Ankle Surgery
Physical Medicine & Rehabilitation
Interventional Spine Care
Mission Peak Orthopedics Commitment to Quality Medical Care
Mission Peak Orthopedics is committed to providing you with high quality medical care. We participate in continuing medical
education to keep our knowledge and skills current and strive to ensure that our patients receive high quality medical care from this
practice.
We also understand that as a patient, you may at times have concerns about our services. We encourage you to communicate your
concerns to our staff. Please tell us if you have a concern-We value your feedback. Please tell us if you have questions about your
care, suggestions to improve the delivery of health care in this office, or complaints about any aspect of your treatment. We appreciate
being part of your health care team and greatly value your feedback. If you have any questions regarding our practice which we are
not able to mutually resolve contact the Alameda-Contra Costa Medical Association at (510)654-5383.
All third parties that receive referrals from this office have the highest possible qualifications and standards for patient care. In the
event that you are dissatisfied with the care that you receive from any entity to which you are referred, please notify your physician at
once, and he or she will make arrangements for you to receive your care elsewhere. Your physician may have a financial interest in
one or more of these entities to which you are being referred for additional care. It is your right to elect to have any eligible facility
provide your care. Please notify your physician if you would prefer to receive care from an entity other than the one in which your
physician has referred you. Your physician wishes to ensure you that the quality of care you receive from this office will not be
affected by your preference for facility in which you receive care.
We offer this NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California (800-6632322 or www.mbc.ca.gov).
Physician Assistants are licensed and regulated by the Physician Assistant Committee (916-561-8780 or www.PAC.CA.GOV)
I have read and understand the options available to me in regards to my medical care. I
understand that medical doctors are licensed and regulated by the Medical Board of
California.
_________________________________________
Patient/Patient Representative Signature
_________________________________________
Patient/Patient Representative Name – Please Print
________________________________________
Date
Ashay A. Kale, MD Soheil Motamed, MD Ricardo Molina, MD
Joshua Van Gompel, DPM Co V. Banh, MD Gabriel Van Gompel, DPM
Lauren Stark, PA-C Victoria Tung, PA-C Keith Bersch, PA-C Ava Novotny, PA-C
Orthopaedic Surgery
Arthroscopy & Sports Medicine
Shoulder & Elbow Surgery
Joint Replacement
Podiatry: Foot & Ankle Surgery
Physical Medicine & Rehabilitation
Interventional Spine Care
FINANCIAL POLICY
CO-PAYMENT
Your co-payment is required at the time of service. Please note: this is a requirement made by your
insurance carrier.
SELF PAY
New Patient - $200 is required prior to your visit for all self-pay and non-contracted insurance plans.
Established Patient - $100 is required prior to your visit for all self-pay and non-contracted insurance plans.
Any overpayment or remaining balance will be adjusted after your visit.
CREDIT CARDS
We accept Visa, MasterCard, Discover or American Express.
SURGERY
In the event your visit turns into a surgery, we will verify your insurance benefits. A deposit for surgery will
be required once your benefits are verified. You will receive separate bills from providers outside of Mission
Peak Orthopaedics, such as the surgery center, anesthesiologist, lab, cardiologist, etc.
PATIENT BILLING STATEMENT
You will receive a monthly statement showing itemized charges and the total due on your account. Payment in full is required within 28
days of statement date. A Late Charge of $25 will be assessed on overdue balances 30 days and older.
There will be a $22 fee charged for returned checks. No credit will be extended to patients having a delinquent account or who have
been referred to a Collection Agency for payment.
Responsibility for payment of your account remains with you at all times; and although you may have an insurance claim pending, we
must look to you for payment regardless of the circumstances involved.
INSURANCE BILLING PROCEDURES
INSURANCE CARDS: We require a copy of your current insurance card and a photo ID at each visit. If we cannot confirm eligibility at
the time of your appointment, you will be asked to reschedule or sign a waiver stating you will be responsible for all charges incurred
during your visit.
PREFERRED PROVIDER PLANS: With certain insurance companies, it is necessary for you to be treated by a Preferred Provider to
ensure complete coverage. If the doctor is not on the preferred provider panel, you will be responsible for allowed and non-allowed
charges. Please contact your insurance carrier directly for a complete listing.
MEDICARE: We accept assignment with Medicare. One secondary insurance claim is submitted as a courtesy.
NON-CONTRACTED PLANS and/or MOTOR VEHICLE CLAIMS: We do not bill non-contracted plans, motor vehicle insurances or
any third party claims.
HMO INSURANCE PLANS: A referral is required from your primary care physician prior to each appointment. If we do not have a
referral at the time of the appointment, you will be asked to reschedule or sign a waiver stating you will be responsible for all charges
incurred during your visit.
WORKER’S COMPENSATION: It is your responsibility to inform the registration desk that the visit is for a work-related injury. If the
claim is DENIED, CLOSED, or if you fail to inform us of the work-related nature of your medical problem, including appropriate claim
information, you will be responsible for all charges.
DURABLE MEDICAL EQUIPMENT: During your visit medical products may be recommended and/or dispensed to assist you with the
healing process. These charges may be reflected on your bill from Mission Peak Orthopaedic or you may receive a separate bill from
the vendor.
_____________________________________
Patient / Parent Signature
_____________________________________
Print Name
_______________________
Date
Ashay A. Kale, MD Soheil Motamed, MD Ricardo Molina, MD
Joshua Van Gompel, DPM Co V. Banh, MD Gabriel Van Gompel, DPM
Lauren Stark, PA-C Victoria Tung, PA-C Keith Bersch, PA-C Ava Novotny, PA-C
Orthopaedic Surgery
Arthroscopy & Sports Medicine
Shoulder & Elbow Surgery
Joint Replacement
Podiatry: Foot & Ankle Surgery
Physical Medicine & Rehabilitation
Interventional Spine Care
How did you hear about our practice?
Referring Physician or PCP
Name: _______________________________________
Insurance or Insurance Website
Family/Friend
Name: _______________________________________
Office Website (www.mportho.com)
Internet Search
Yelp
Yellow Pages (YP)
Newspaper
Which One? ___________________________________
Radio Station
Which Station? ___________________________
Television
Which channel? __________________________
Other
Please List: _______________________________________
Fremont Office: 39350 Civic Center Drive, Suite 300, Fremont, CA 94538
Hayward Office: 27206 Calaroga Avenue, Suite 107, Hayward, CA 94545
Pleasanton Office: 5924 Stoneridge Drive, Suite 110, Pleasanton, CA 94588
www.mportho.com
Phone 510.797.3933
Phone 510.300.9898
Phone 925.846.6200
Fax 510.797.5184
Fax 510.797.5184
Fax 510.797.5184