Del Mar M.E.D.	Dina Massry, M.D.

12395 El Camino Real, Ste 200	Jeff Eaton, M.D.

San Diego, CA 92130	Jennifer Eastlack, M.D.

PH: 858-755-6647 F: 858-755-5947

www.DelMarMed.com

DATE _____________/___________/_____________

NAME: LAST________________________________________________________ FIRST_________________________________________________ MIDDLE INITIAL__________

PREFERRED NAME (IF DIFFERENT FROM ABOVE)_____________________________________________________________________________________________________

ADDRESS________________________________________________________________________________________________________________________________________

CITY______________________________________________________________________ STATE________________________________ ZIP______________________________

HOME PHONE_______________________________________ CELL_______________________________________ WORK_______________________________ EXT_______

PERMISSION TO LEAVE MESSAGE: HOME □ YES □ NO CELL □ YES □ NO BEST NUMBER TO REACH YOU: _____________________________

EMAIL FOR PATIENT PORTAL ACCESS: _______________________________________________________________________________________________+____________

PRIMARY CARE DOCTOR___________________________________________________________________________ PHONE_______________________________________

REFERRING PHYSICIAN____________________________________________________________________________ _PHONE_______________________________________

DATE OF BIRTH _______/_____/______ SEX □ F □ M SOCIAL SECURITY NUMBER _________ /_______ /__________

MARITAL STATUS: □ SINGLE □ DIVORCED □ PARTNER □ WIDOWED □ MARRIED (spouse name) _______________________________________

ETHNICITY_____________________________________________________________________________ PRIMARY LANGUAGE____________________________________

RESPONSIBLE PARTY IF MINOR □ PARENT □ GUARANTOR RELATIONSHIP (other than parent)

NAME ______________________________________________________ ADDRESS ___________________________________________________________________________

CITY________________________________________ STATE_________________ ZIP______________________HOME PHONE _______________________________________

EMERGENCY CONTACT NAME, LAST____________________________________ FIRST ____________________________________RELATIONSHIP____________________

ADDRESS_______________________________________________________________CITY_____________________________STATE______________ZIP__________________

HOME PHONE NUMBER (__________) ____________ -______________ WORK / CELL PHONE NUMBER (_________) ____________-_____________ EXT.____________

PHARMACY NAME___________________________________________ LOCATION_________________________________________________________________________

PHONE (___________) __________-________________ FAX (____________) __________ -_______________

____________________________________________________________________________ _______________________________________________________________________________

PATIENT SIGNATURE IF PATIENT IS A MINOR, PARENTS SIGN HERE FOR PERMISSION FOR TREATMENT

PLEASE SIGN THE FOLLOWING PAGES

Del Mar M.E.D.	Dina Massry, M.D.

12395 El Camino Real, Ste 200	Jeff Eaton, M.D.

San Diego, CA 92130	Jennifer Eastlack, M.D.

PH: 858-755-6647 F: 858-755-5947

www.DelMarMed.com

RELEASE/ASSIGNMENT/ACKNOWLEDGEMENT

I consent to medical examination, treatment, and diagnostic studies advised by the physician. I authorize insurance benefits be paid directly to the practice. Del Mar M.E.D. will offer what they feel, in their medical opinion, is medically necessary for my healthcare.

I HEREBY AUTHORIZE DEL MAR M.E.D. TO RELEASE PERTINENT INFORMATION REGARDING MY CARE TO OTHER PHYSICIANS AND/OR INSURANCE COMPANIES HOLDING POLICIES ON ME.

I authorize my insurance company to directly remit payment to Del Mar M.E.D. for medical and surgical services provided.

I understand some services advised by my doctor may or may not be covered by insurance. I understand that I am financially responsible for any outstanding balance and will promptly pay this in full within 30 days of receiving a bill. I understand accounts 120 past due will be transferred to a third party collections agency and that I will be responsible for any and all fees accosicated with this transfer.

I UNDERSTAND THAT BY NOT PROVIDING THE OFFICE WITH ALL INFORMATION REQUESTED AND/OR COPIES OF MY INSURANCE CARD(S) AT TIME OF SERVICE, THIS COULD CAUSE A DELAY IN THE PROCESSING OF MY CLAIM AND I COULD CONSEQUENTLY RECEIVE A BILL FOR THESE SERVICES.

My signature below indicates my acceptance/understanding of the above statements.

NOTICE TO CONSUMERS

Medical doctors are licensed and regulated by the

Medical Board of California

(800) 633-2322

www.mbc.ca.gov

Signature of patient or parent/guardian: ________________________________Date: _______________

PLEASE SIGN THE FOLLOWING PAGES

NOTICE OF PRIVACY PRACTICES

To our patients: This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996. (HIPAA)

Our Commitment to your Privacy: Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information:

Use and disclosure of your health information

The following circumstances may require us to use or disclose your health information:

To public health authorities and health oversight agencies that are authorized by law to collect information.

Lawsuits and similar proceedings in response to a court or administrative order.

If required to do so by a law enforcement official.

When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.

If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

To federal officials for intelligence and national security activities authorized by law.

To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

For Workers Compensation and similar programs.

Your rights regarding your health information

Communications: You can request that your physician’s office communicate with you about your health and

related issues in a specified manner or at a certain location. For instance, you may request that we contact you

at home, rather than work. We will accommodate reasonable requests.

You can request a restriction in our use or disclosure of your health information for treatment, payment, or health

care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we are bound by our agreement except when otherwise required by the law, in emergencies, or when the information is necessary to treat you.

You have the right to inspect and obtain a copy of the health information that may be used to make decision

about you, including patient medical and billing records, but not including psychotherapy notes. You must

submit your request in writing to Jeff Eaton, M.D., Dina Massry M.D. or Jennifer Eastlack M.D., Scripps Medical Building, Suite 200, 12395 El Camino Real, San Diego, CA 92130.

You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the

information is kept by or for our practice. To request an amendment, your request must be made in writing and

submitted to Jeff Eaton, M.D., Dr.Dina Massry, M.D., or Jennifer Eastlack M.D., Scripps Medical Building, Suite 200, 12395 El Camino Real, San Diego, CA 92130. You must provide us with a reason that supports your request for amendment.

Right to a copy of this notice. You are entitled to receive a copy of this notice of Privacy Practices. You may ask

us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our front desk

receptionist.

Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our

practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our

office, please contact our office manager at 858-755-6647. All complaints must be submitted in writing. You will

not be penalized for filing a complaint.

Right to provide an authorization for other uses and disclosures. If a disclosure is made for any reason other than

treatment, payment or operation, you have the right to an account of those disclosures. Our practice will obtain

your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable

law.

If you have any questions regarding this notice or our health information privacy policies, please contact our Office Manager at

858-755-6647. We reserve the right to revise this notice at any time without notification.

I hereby acknowledge that I have been presented with a copy of Jeff Eaton, Dina Massry and/or Jennifer Eastlack M.D.’s Notice of Privacy Practices.

_____________________________________________________________ __________________________________

Signature of patient or parent/guardian Date

Patient’s Name: (please print) _________________________________________________________________________

Del Mar M.E.D.	Dina Massry, M.D.

12395 El Camino Real, Ste 200	Jeff Eaton, M.D.

San Diego, CA 92130	Jennifer Eastlack, M.D.

PH: 858-755-6647 F: 858-755-5947

www.DelMarMed.com

Cancellation Policy

We take pride in making a conscious effort to accommodate our patients’ schedules and that each patient is seen in a timely fashion. We believe that your time is as valuable as our own.

If you are unable to keep your appointment, please give a 24 hours’ notice so that someone else needing our services may be seen at that time. We will be happy to re-schedule your appointment for a future date.

I understand that several failures to cancel or re-schedule an appointment without a 24 hour notice can result in a No Show appointment charge of $50.00.

Patient or Parent/Guardian Signature ________________________________ Date _____________

Printed Name ___________________________________