I certify that I and/or my dependent(s) have insurance coverage with the above insurance listed and assign directly to Dr. Masih all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I understand that I will be responsible for all collection/attorney fees if my account becomes delinquent. I authorize the use of my la signature on all insurance submissions. The above-named physician may use my healthcare information and may disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This release is valid until I notify the practice in writing with any changes.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intension of the parties that this agreement binds all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The party's consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05; however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below.

IF ANY PROVISION OF THIS ARBITRATION AGREEMENT IS HELD INVALID OR UNENFORCEABLE, THE REMAINING PROVISIONS SHALL REMAIN IN FULL FORCE AND SHALL NOT BE AFFECTED BY THE INVALIDITY OF ANY OTHER PROVISION.

I UNDERSTAND THAT I HAVE THE RIGHT TO RECEIVE A COPY OF THIS ARBITRATION AGREEMENT.

BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

EFFECTIVE AS OF THE DATE OF FIRST MEDICAL SERVICES.

• We will file all insurance for your care. You will be responsible for all co-pays, coinsurance and deductibles at the time of visit.
• All self-pay patients will be expected to pay in full on their first visit.
• All self-pay patients and any patient with an outstanding balance over $250 will be required to apply for CareCredit prior to any payment arrangements being set up. You may elect not to apply for CareCredit; however, you will be responsible for all payments due at the time of service.
• All self-pay patients will be required to pay for elective surgery prior to surgery.
• We will submit to all patients (2) statements of current patient balances by mail. If we receive no response to these statements, we will begin the collection process immediately. If your account is sent to an outside collection agency, you will be responsible for all collection and legal fees.
• We encourage you to stay in contact with our office regarding financial issues, as we will attempt to work with you.
• We accept MasterCard, Visa, American Express, Cash, Check and CareCredit.
• Returned Check fee is $25.
• If you cancel your appointment in less than 24 hours or “No Show” for an appointment, you may incur a $25 fee.

I have read and understand the above payment policy.

This letter is to educate our patients in the way that your new insurance or your new insurance policy will affect you in our office. These changes will only affect Anthem Blue Cross and Blue Shield of CA patients. Although our office is still in-network with “some” of the Blue Cross and Blue Shield plans, we are not in-network with the new Covered CA plans and the Narrow Network plans they are offering.

For our Anthem Blue Cross Covered CA or Narrow Network patients, unfortunately at this time our office will “not” be able to accept insurance or schedule appointments at this time. The reason that we will be unable to see patients at this time is because currently the Blue Crossʼ system is unreliable in providing accurate information regarding whether or not a plan is a PPO or an EPO. As a result, we are seeing patients who should have out-of-network benefits with a PPO plan, but do not because their plan is truly an EPO. This is causing an unexpected cost to patients that they may not be prepared for. Blue Cross is also inconsistent with the labeling of their insurance ID cards, showing whether or not the plan is a Covered CA plan or a Narrow Network plan. Since we currently cannot rely on the information they are producing and we are not in-network with their new Covered CA and Narrow Network plans, we will “not” be seeing patients with these plans.

For our Blue Shield Covered CA and Narrow Network patients, we will be able to accept your insurance at this time, however, you will be charged for what Blue Shield allows for a service at the time of your visit. You will be charged the rate that our current contract with Blue Shield allows and not the 30% fee reduction that the new Covered CA and Narrow Network plans allow. The reason for this is because Blue Shield is processing our claims as out-of-network and mailing the payments to the subscriber of the insurance. If you want an explanation as to what your out-of-network benefits are, you should contact your insurance for the most accurate explanation.

Dr. Masih apologizes for any inconvenience that this is causing you, but in order to provide the highest level of care without compromising patient care both physically and financially, this is the policy that we have to implement at this time.

If you have any other questions regarding this policy, you may speak with the billing department for further explanation. Thank you for your understanding and patience during this transition period.

In general, the Health Information Patient Accountability Act (HIPAA) privacy rule gives individuals the right to request a restriction on use or disclosure of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.

This office will generally contact patients by written communication or phone calls. We will send letters or call the number the patient has provided on the Patient Information sheet.

DMEPOS = Durable Medical Equipment, Prosthetics, Orthotics and Supplies

Supplier = Center for Spine and Sports Rehabilitation Medicine

CMS = Centers for Medicare and Medicaid Services

• 1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services.
• 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any change to this information must be reported to the National Supplier Clearinghouse within 30 days.
• 3. An authorized individual (whose signature is binding) must sign the application for billing privileges.
• 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.
• 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.
• 6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty.
• 7. A supplier must maintain a physical facility on an appropriate site. This standard requires the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records.
• 8. A supplier must permit CMS or its agents to conduct on-site inspections and ascertain the supplier’s compliance with these standards. The supplier location must be accessible to the beneficiaries during reasonable business hours and must maintain a visible sign and posted hours of operation.
• 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll-free number available through directory assistance. The exclusive use of a beeper, answering machine or cell phone during posted business hours is prohibited.
• 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product-related liability and completed operations.
• 11. A supplier must agree to not initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician’s oral orders unless an exception applies.
• 12. A supplier is responsible for delivery and must instruct beneficiaries on the use of Medicare covered items, and maintain proof of delivery.
• 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
• 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, any Medicare-covered items it has rented to beneficiaries.
• 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.
• 16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.
• 17. A supplier must disclose to the government any person having ownership, financial or control interest in the supplier.
• 18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number.
• 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.
• 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.
• 21. A supplier must agree to furnish the CMS any information required by the Medicare statute and implementing regulations.
• 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services for which the supplier is accredited, in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals).
• 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened.
• 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare.
• 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.
• 26. Must meet the surety bond requirements specified in 42 CFR § 424.57(c).
• 27. A supplier must obtain oxygen from a state-licensed oxygen supplier.
• 28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 CFR § 424.516(f).
• 29. DMEPOS suppliers are prohibited from sharing a practice with certain Medicare providers and suppliers.
• 30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.