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Hooman M. Melamed, MD PATIENT DEMOGRAPHICS
Patient Name _____________________________________________________________ Date____/____/______
Home Address ________________________________________________________________________________
City_______________________________________ State __________________________ Zip_______________
Home Phone (_____) _____-________ Cell Phone (_____) _____-________ Work Phone (_____) _____-________
Email _______________________________________________________________________________________
Preferred Method of Contact: □ Home # □ Cell # □ Work # □ Email
SS# __________________________________ Date Of Birth ____/____/______ Gender___________________
Religious Preference ___________________________________________________________________________
Employer _____________________________________ Contact Person _________________________________
Employer Address _____________________________________________________________________________
State_______________________________ Zip______________ Employer Phone (_____) _____-_________
Occupation __________________________________________________________________________________
□ PPO / Private Inurances □ Work Comp □ Auto □ Personal Injury Other
INSURANCE CARRIER ___________________________________________________________________________
Address ______________________________________________________________________________
City____________________________________ State ______________________ Zip______________
Phone (_____) _____-________ Fax (_____) _____-________
ID # ____________________________Group#___________________ Effective _____/_____/______
Relationship to insured _______________________________________ SS# ______________________
DOB ____/____/______
Medicare #___________ Part A__________ Part B__________ Effective Date__________ Parts A&B_________
SECONDARY INSURANCE ________________________________________________________________________
Address ______________________________________________________________________________
City__________________________________ State _______________________ Zip_______________
Phone (_____) _____-________ Fax (_____) _____-________
Group/Claim # _______________________________________________ Effective ____/____/______
WORKERS COMPENSATION CARRIER ______________________________________________________________
Address ______________________________________________________________________________
City____________________________________ State _______________________ Zip______________
Phone (_____) _____-________ Fax (_____) _____-________
Claim # ______________________________________ Date Of Injury_______________________
Claims Adjuster ________________________________________________________________________
ATTORNEY ____________________________________________________________________________________
Address ______________________________________________________________________________
City_______________________________ State ____________________ Zip______________
Phone (_____) _____-________ Fax (_____) _____-________
Date Of Injury_______________________
Page 2 of 11
Patient Name _____________________________________________________ Date ____/____/______
Please provide the doctor with your physician’s information. Write down as much information as you can provide, (I.E. Name & City) so that we may keep them informed of your progress.
REFERRING PHYSICIAN
Name ________________________________________________________________________________
Specialty _____________________________________________________________________________
Address ______________________________________________________________________________
City_______________________________ State ____________________ Zip______________
Phone (_____) _____-________ Fax (_____) _____-________
INTERNIST/PRIMARY CARE PHYSICIAN /NAME SPECIALTY
Name ________________________________________________________________________________
Specialty _____________________________________________________________________________
Address ______________________________________________________________________________
City_______________________________ State ____________________ Zip______________
Phone (_____) _____-________ Fax (_____) _____-________
IF LEGAL CARE, PLEASE COMPLETE THE FOLLOWING INFORMATION
Attorney Name ________________________________________________________________________
Address ______________________________________________________________________________
City_______________________________ State ____________________ Zip______________
Phone (_____) _____-________ Fax (_____) _____-________
WORKERS COMPENSATION INFORMATION (IF APPLICABLE)
Insurance _____________________________________________________________________________
Address ______________________________________________________________________________
City_______________________________ State ____________________ Zip______________
Adjustor __________________________________________________ Phone (_____) _____-________
Claim# _______________________________________ Date of Injury ____/____/______
Please use the back of this form for any additional physician information.
Hooman M. Melamed, MD PHYSICIAN INFORMATION
Page 3 of 11
Hooman M. Melamed, M.D. Orthopaedic Spinal Surgeon ph (310) 574-0400 fax (310) 574-0422
□ 13160 Mindanao Way, Suite 300 □ 8750 Wilshire Blvd., Suite 350 Marina del Rey, CA 90292 Beverly Hills, CA 90211
All questions contained in this questionnaire are strictly confidential and will be part of your medical record.
NAME (Last, First, M.I.) DOB AGE
ADDRESS
PRIMARY PHYSICIAN Ph no. (_____) ______-_______
REFERRING PHYSICIAN Ph no. (_____) ______-_______
HOW DID YOU HEAR ABOUT DR. MELAMED? _______________________________________________________________________
_____________________________________________________________________________________________________________
HISTORY OF PRESNET ILLNESS
MY CHIEF COMPLAINT IS:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
HOW DID THIS INJURY OCCUR?
______________________________________________________________________________________________________________
WHEN DID SYMPTOMS FIRST START?_______________________________________________________________________________
_____________________________________________________________________________________________________________
Are they getting: Did the symptoms start: Does pain wake you up at night time?
□ Better
□ Suddenly
□ Yes
□ Worse
□Gradually
□No
□ Staying the Same
DESCRIBE QUALITY OF PAIN: □ Dull □ Sharp □ Throbbing □ Burning □ Stabbing □ Ache
PAIN DETAILS: Relieving or aggravating factors are: bending, lifting, sitting, standing, walking, lying , rest, ice, pain meds
(example: sitting 15 min relieves pain or standing 30 min aggrevated pain)
What makes it better? (Relieving factor) ____________________________________________________________________________
What makes it worse? (Aggravating factor) __________________________________________________________________________
I can walk: □ 0-1 blocks □1-3 blocks □3-5 blocks □ 5-7 blocks □>7 blocks
ASSOCIATED PROBLEMS: (Please check all that apply)
□ Do you have weakness? □ Arms □ Legs □ Both
□ Do you have difficulty controlling your bladder function?
□ Do you have difficulty controlling your bowel function?
□ Do you have difficulty with balance or coordination of arms and legs?
□ Do you have difficulty with fine finger movements?
□ Has your hand-writing gotten worse lately?
□ Do you suffer from migraines /headaches?
DATE ____/____/______
□ Private Insurance
□ Workers Comp
□ Auto/Personal Injury
Page 4 of 11
HISTORY OF PRESNET ILLNESS cont.
HAVE YOU HAD ANY OF THE FOLLOWING TREATMENTS: PLEASE CHECK ALL THAT APPLY □ NONE
Epidurals: □ Yes □ No If yes, then what levels? __________ How many times? I II >III Dates: ___________________
Are you: □ better □ same □ worse
Physical Therapy: How many sessions? ____________ Dates: From ____/____/______ to ____/____/______
Are you: □ better □ same □ worse
Chiropractic Treatment: How many sessions? ______________ Dates: From ____/____/______ to ____/____/______
Are you: □ better □ same □ worse
Acupuncture: How many sessions? ______________ Dates: From ____/____/______ to ____/____/______
Are you: □ better □ same □ worse
DIAGNOSTIC STUDIES / TESTS FOR YOUR CONDITION □ NONE
MRI CT
X-Ray EMG/NCS (Nerve test)
□ Lumbar Spine
□ Lumbar Spine
□ Lumbar Spine
□ Arms
□ Thoracic Spine
□ Thoracic Spine
□ Thoracic Spine
□ Legs
□ Cervical Spine
□ Cervical Spine
□ Cervical Spine
□ Both
□ Dates: ____/____/______
□ Dates: ____/____/______
□ Dates: ____/____/______
□ Dates/Doctor _____________________
PAST MEDICAL HISTORY: HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLE □ NONE □ AIDS or HIV
□ High Blood Pressure
□ Diabetes
□ Venereal Disease
□ Measles
□ Lung Disease
□ Small Pox
□ Mitral Valve Prolapse
□ Bronchitis
□ Pneumonia
□ Infectious Mono
□ Stomach Ulcer
□ Sleep Apnea
□ Osteomalacia
□ Blood Transfusion
□ Stroke
□ Hepatitis
□ Other: (please list)
□ Tuberculosis
□ Polio
□ Epilepsy/Seizures
□ Bleeding Tendency
□ Osteoporosis
□ Hemorrhoids
□ Parkinsons
□ Aneurysm
□ Asthma
□ Thyroid Disease
□ Bladder Infections
□ Diphtheria
□ Low Blood Pressure
□ Heart Disease
□ Migraine Headaches
□ Anemia
□ Rheumatoid Arthritis
□ Kidney Disease
□ Whooping Couch
□ Heart Failure
□ High Choloesterol
□ Rheumatic Fever
□ Glaucoma
□ Heart Attack
PAST SURGICAL HISTORY □ NONE
Year Reason Hospital
OTHER HOSPITALIZATIONS □ NONE
Year Reason Hospital
LIST YOUR PRESCRIPTION AND OVER-THE-COUNTER DRUGS AND VITAMINS □ NONE
Name of Drug/ Vitamin Strength Frequency Taken
ALLERGIES □ NONE
Name of Drug Reaction you had
Hooman M. Melamed, MD | Orthopaedic Spinal Surgeon
Page 5 of 11
REVIEW OF SYSTEMS: PLEASE CHECK ALL THAT APPLY □ NONE
Musculoskeletal □ Joint pain
□ Back pain
□ Weakness of muscles or joints
□ Muscle pain or cramps
□ Joint stiffness or swelling
□ Cold Extremities
□ Difficulty in walking
General / Constitutional □ Fevers □ Chills □ Nausea Vomiting □ Loss of appetite
Hematologic / Lymphatic □ Lethargy □ Lumps under skin □ Slow to heal after cuts □ Easily bruising
Skin / Breast □ Rashes □ Eczema □ Slow to heal after cuts □ Easily bruising
Cardiovascular □ Heart Trouble □ Chest Pain □ Palpitation □ Shortness of breath while walking
Eyes / Ears / Nose / Throat □ Sore throat or voice change
□ Swollen glands in neck
□ Hearing loss or ringing
□ Ear ache
□ Chronic sinus problems
□ Nose bleeds
□ Bleeding gums
□ Wear glasses/contact lenses
□ Blurry or double vision
Respiratory □ Trouble breathing □ Frequent coughing □ Production of sputum □ Blood in sputum
Gastrointestinal □ Bloating □ Frequent diarrhea □ Constipation □ Rectal bleeding □ Abdominal pain
Genitourinary □ Frequent urination
□ Blood in urine
□ Burning or painful urination
□ Impotence
□ Incontinence or dribbling
Ob / GYN □ FEMALE: Number of Pregnancies ____________ □ Number of deliveries _______________
Endocrine □ Excessive thirst and urination □ Heat or cold intolerance □ Skin becoming dryer
Neurological □ Light headed or dizzy □ Numbness or tingling sensations □ Tremors □ Seizures
Psychological □ Memory loss or confusion
□ Nervousness
□ Depression
□ Insomnia
□ Problem controlling mood
□ Sleeping too much
LIST ANY MEDICAL PROBLEMS THAT RUN IN YOUR FAMILY □ NONE Age Significant Health Problem If Deceased, then cause of death
Father
Mother
Sibling □ M □ F
□ M □ F
□ M □ F
Grandmother (Maternal)
Grandfather (Maternal)
Grandmother (Paternal)
Grandfather (Paternal)
PERSONAL / SOCIAL HISTORY
Height: _________________ Weight: ___________lbs
CURRENT EMPLOYMENT STATUS: Are you currently employed? □ Yes □ No
If yes, then □ Full time □ Part Time – Hours per week _________
If no, then □ On disability □ On partial disability □ Unemployed
Job type □ Heavy labor □ Moderate activity □ Desk work
MARITAL STATUS: □ Single □ Partnered □ Married □ Divorced □ Widowed
Illicit / Recreational drug use □ No □ Yes If yes, how often? _______________________________
Alcohol Do you drink? □ Yes □ No If yes, # of years? _____________ How many drinks / week?__________
Tobacco Do you use tobacco? □ Yes □ No If yes, # of years______________ Or, year quit ______________
Cigarettes________#/day Chew ________#/day Pipe________#/day Cigars________#/day
DATE: ____/____/______ SIGNATURE: _________________________________________________________________________
Hooman M. Melamed, MD | Orthopaedic Spinal Surgeon
Page 6 of 11
PAIN DESCRIPTION
Where is your pain right now?
Mark the areas on the body below where you feel the described sensations, using the appropriate symbols. Mark the areas of radiation, including all affected areas.
How bad is your pain right now? (Indicate on the line below)
0----------1----------2----------3----------4----------5----------6----------7----------8----------9----------10 No Pain Intermediate Pain Worst Pain
I can tolerate my pain at a score of: __________ Please check the box that indicates the duration of your pain:
□ Continuous □ Positional □ Intermittent (on/off) □ Unable to rate
Patient Name _________________________________ Age ________ Date ____/____/______
Page 7 of 11
Hooman M Melamed, M.D. PATIENT CONSENT FORM
ph 310.574.0400 - fax 310.574.0422
13160 Mindanao Way, Suite 300 | Marina del Rey, CA 90292 8750 Wilshire Blvd., Suite 350 | Beverly Hills, CA 90211
Authorization for treatment and release of information: (Please initial ones that apply)
___ I consent for this provider to render the treatment set forth as ordered by my physician
___ I give authorization for treatment to be provided in areas not totally isolated from other patients and personnel
___ This authorization, or photocopy of same, authorizes the release of any medical information necessary for treatment and/or to process
claims for services rendered by this provider.
Alternate contact information: Dr. Melamed and/or his staff have my consent to (Please initial ones that apply)
___ Leave medical information on my home answering machine or email
___ Leave medical information on my cell phone
___ Contact me at my place of employment
___ Leave medical information on Family, Friends or Co-workers voicemail
___ Leave medical information on Family, Friend or Co-workers email
Signature of Patient/Guardian___________________________________ Date____/____/______
Guardian Name (please print) ____________________________Relationship _____________________
Assignment of Benefits
REIMBURSEMENT COVERAGE
I request and authorize my insurance and/or Medicare to make payment for benefits on my behalf to Hooman M. Melamed, M.D.
Signature of Patient/Guardian___________________________________ Date____/____/______
IF POLICY HOLDER IS OTHER THAN THE PATIENT, please complete the following. I, the policy holder, request and authorize my insurance
company and /or Medicare to make payments for benefits on behalf of this patient to Hooman M. Melamed, M.D.
Signature of Patient/Guardian___________________________________ Date____/____/______
Please Print Name _____________________________________________
PLEASE PROVIDE PROOF OF INSURANCE COVERAGE UPON COMPLETION OF THIS FORM
Assignment and Authorization: I hereby assign payment(s) directly to Hooman M. Melamed, M.D. for services and supplies provided to me of
the insurance benefits otherwise payable to me. I understand I am financially responsible to Hooman M. Melamed, M.D. for the charges not
covered by this authorization. I agree to forward any insurance payments made directly to me for services upon presentation of a bill from
Hooman M. Melamed, M.D..
Signature of Patient/Guardian___________________________________ Date____/____/______
Please Print Name _____________________________________________
A copy of this authorization shall be considered as valid as the original and valid for the duration of my care. I understand I am liable for all
charges incurred should my insurance not pay for these services (Except for Worker’s Compensation)
Signature of Patient/Guardian___________________________________ Date____/____/______
Please Print Name _____________________________________________
Page 8 of 11
Date ____/____/______
Patient’s Name __________________________________________
Insurance Plan __________________________________________
INSURANCE ACKNOWLEDGEMENT
Please be aware that D.I.S.C. (Diagnostic and Interventional Surgical Center) is not a contracted provider
with your insurance. We will submit a claim for services rendered to your insurance company. You will
be responsible for any balance unpaid by your insurance.
Please not that your referring provider’s contact affiliation will have no bearing on the processing of the
claims for X-rays. There is no affiliation with Mink Radiology. This notice is for X-rays taken at 13160
Mindanao Way, Marina del Rey, CA 90292.
Should you have any questions regarding the billing associated with your x-rays please contact Marina
Physician Services at 310.574.0442.
__________________________________________________
PATIENT SIGNATURE
Page 9 of 11
APPEAL AUTHORIZATION FORM
FOR A DESIGNATED REPRESENTATIVE
Date: _______________
Member Name: ____________________________
Member ID#: ____________________________
To: _____________________________ and/or __________________________________
Insurance Company Employer
I, ______________________________________ (patient name) hereby authorize Hooman
Melamed, M.D. (“healthcare provider”) and/or its designee, which shall include but not be limited to, a
law firm, an attorney or any other company or organization hired by healthcare provider, to appeal any
claim payment and/or benefit determination made by the insurance company, administrator and/or my
employer’s health and welfare benefit plan. I understand that by signing this Authorization, the law firm,
attorney or other company or organization will be hired and paid directly by healthcare provider and will
be representing my rights, which were previously assigned to healthcare provided pursuant to the
Assignment of Benefits.
By signing this Authorization, I understand and agree that either healthcare provider or the entity
that they hire will have direct communication with the insurance company, administrator of the health and
welfare benefit plan or my employer. I further instruct and authorize my insurance company,
administrator of my health and welfare benefit plan or employer to communicate directly with healthcare
provider or any designated entity that they hire to represent these interests. I understand that these
communications include ALL medical and financial information contained in my claim file.
This Authorization shall be valid for three (3) years from the date stated herein and a photocopy of
this Authorization shall be valid as an original. This Authorization shall remain valid until revoked in
writing by the Member and sent to both the healthcare provider and the insurance company /administrator
/employer health and welfare benefit plan.
______________________________________________
Signature of Member or Legal Guardian/Representative
Copyright property of Robert B. Silverman, all rights reserved. Any duplication is expressly prohibited
Page 10 of 11
ASSIGNMENT OF RIGHTS AND BENEFITS I hereby authorize and instruct my insurance company and/or the Administrator of my health and welfare benefit
plan and/or any other third party administer that is responsible for the issuance of reimbursements and/or payments
of healthcare expenses (collectively, the “INSURANCE COMPANY”) that I incur, to be paid directly to Hooman
Melamed, M.D. in their name or their designated associates or assignee(s) (collectively “PROVIDERS”) and shall
be mailed directly to 13160 Mindanao Way Suite 300, Marina Del Rey, CA 90292.
I hereby assign, whether signing as a patient or patient’s agent, all rights and benefits under my plan of insurance or
health and welfare benefit plan to any and all PROVIDERS. I give express right to PROVIDERS to obtain the plan
of insurance, the health and welfare benefit plan, the Summary Plan Description and/or any other relevant
information from INSURANCE COMPANY, Employer or any of their associates or agents. I also provide express
consent and give full rights to PROVIDERS to appeal, any adverse benefit decision affecting any rights that I am
entitled to under my plan of insurance or my health and welfare benefit plan. This assignment shall allow
PROVIDERS to file any necessary appeal(s) on my behalf to the INSURANCE COMPANY, Employer,
Administrative agency or any of their associates or agents.
This assignment further assigns PROVIDERS with the rights to obtain from INSURANCE COMPANY, Employer
or any of their agents or associates all information necessary for the determination of benefits allowed under the
plan of insurance or the health and welfare benefit plan and permits the direct disclosure to PROVIDERS of all
information including benefits provided including benefits and payments made on my behalf, limits and exclusions
of benefits and reasons for denial of benefits or reduction in charges for services rendered.
This assignment shall allow PROVIDERS to take any and all necessary legal action on my behalf, whether in
Federal or State Court, and shall include any and all legal rights under ERISA as well as any and all applicable
State Court causes of actions to obtain any and all financial and/or medical benefits or any other damages that I am
legally entitled to receive pursuant to the terms of the plan of insurance, health and welfare benefit plan, ERISA,
State Law or any other applicable Federal or State law. A photocopy of this assignment shall be considered as
effective and valid as the original.
I understand that this is an assignment of certain rights and that this does not affect my obligation to pay any
deductible, co-pay or co-insurance obligation. I also understand that my insurance may disallow certain diagnoses
or services as medically uncovered, medically unnecessary, cosmetic or simply that the services received are
excluded from coverage. I agree and understand that this Assignment does not alter my financial obligation to
PROVIDER in accordance with other documents that I may have signed.
In the event that my INSURANCE COMPANY disregards this Assignment and sends payments to me, I
understand that I will endorse and immediately deliver all funds to PROVIDER within 48 hours of receipt. I
understand that the intentional and knowing misappropriation of this payment may be a crime, that PROVIDER
will file a criminal complaint for such conduct and that I may be subject to criminal prosecution.
I further understand that this Assignment does not in any way affect or alter my plan of insurance or health and
welfare benefit plan which is an agreement between me and INSURANCE COMPANY. I understand that by
signing this Assignment, this will allow PROVIDER to assist me in the processing of my claim(s), filing of an
appeal, overturning any adverse decision, collect any payments issued, file complaints with the appropriate
authorities/agencies, filing of any necessary lawsuits and to hire any necessary third parties, such as independent
attorneys or billing and collection organizations to assist PROVIDER in the enforcement of the assigned rights.
This is a direct assignment of my rights and benefits under an insurance policy or health and welfare benefit plan,
including, but not limited to, any Plan that is subject to ERISA or PPACA. This Assignment shall be effective for
any and all prior medical services received by PROVIDER.
. .
Patient/Parent/Guardian/Representative - Signature Date
Copyright property of Robert B. Silverman, all rights reserved. Any duplication is expressly prohibited
Page 11 of 11
HEALTH AND WELFARE BENEFIT PLAN REQUEST
Patient/Employee Name: __________________________________ Patient Date of Birth: ___________
Insurance Company: _______________________________ Patient ID: ____________________
Employer Name:___________________________________ Group ID: _____________________
Dear Plan Administrator/Employer:
I hereby authorize Hooman Melamed, M.D. (“healthcare provider”) and/or its designed agent to receive
on my behalf a copy of the Summary Plan Description pertaining to my health and welfare benefit plan (“SPD”)
and/or a copy of the entire health and welfare benefit plan. This request is made consistent with the Assignment
of Rights and Benefits that I have signed in favor of my healthcare provider. Please accept this letter as my formal
written request that you send my healthcare provider the SPD and/or the full health and welfare benefit plan
including all exclusions, limitations and ALL CHANGES made to the health and welfare benefit plan within the
last 5 years. In the event that you only send the SPD, my healthcare provider and/or their designed agent, shall
be entitled to request, at their discretion, a copy of the full health and welfare benefit plan.
In accordance with ERISA and other federal laws, the Employer and/or Plan Administrator is legally
obligated and required to provide the SPD and/or entire plan to me (a plan participant) immediately after my
request. (http://www.dol.gov./dol/topic/health-plans/planinformation.htm) I am aware that under Federal Law,
failure to provide the SPD and/or entire plan can result in financial penalties, currently set at $110.00 per day, in
addition to any attorneys’ fees incurred should legal action be necessary in order to compel compliance.
Please send the SPD and/or Plan electronically to:
or
Please mail a copy of the SBD and/or Plan to:
Hooman Melamed, MD
13160 Mindanao Way Suite 300
Marina Del Rey, CA 90292
____________________________________ ____________________________________
Patient/Employee/Legal Rep. Name (Print) Patient/Employee/ Legal Rep. (Signature)
Copyright property of Robert B. Silverman, all rights reserved. Any duplication is expressly prohibited