Patient Forms

Several patient forms are available for download in Microsoft Word format.

Facts Sheet 
  Download (208KB)
This document contains information about our office and it's policies, including information about:

• office hours
• prescriptions
• test results
• billing questions
• scheduling appointments
• insurance authorization requirements
• requests for medical records
• payment policy
• directions and parking

New Patient Information Form:
    Download (91KB) This document contains forms for new patients. They are to be filled-out COMPLETELY and brought to your appointment along with ANY x-rays and/or scans pertaining to your spine.

Film Return/Distruction Form:
    Download (51KB) Instructs LA Spine Institute to destroy, mail, or lets them know that you will pick up your films.

Patient Consent For Use and Disclosure of Protected Health Information:
    Download (12KB)

Patient Authorization For Use and Disclosure of Protected Health Information For Purpose Requested by the Practice: 
   Download (22KB)

The Spine Institute Notice of Privacy Practices:  
  Download (38KB)

OFFICE HOURS

• The office is open Monday through Friday, 8:00am - 5:00pm. (office closes at 4:00pm on Fridays)
• The switchboard is open from 9:00am to 12:00pm and 2:00pm to 5:00pm
• The answering service will take messages when the switchboard is closed.

OFFICE LOCATIONS

• The Spine Institute (Mark Goodson Building)
  444 South San Vicente,
  Suite 901
  Los Angeles, Ca 90048
  Phone: 888-774-6376
  (Click here for directions)
  
  
  
  
• The Spine Institute (Medical Imaging Building)
  2811 Wilshire Boulevard,
  Suite 850
  Santa Monica, CA 90403
  Phone: 888-774-6376
  (Click here for directions)

PRESCRIPTIONS

• Please have your pharmacy call us on about all "refill" prescriptions.
• If your prescription will run out over the weekend, please have your pharmacy call our office on the preceding Thursday.
• Prescriptions will not be filled after 5:00pm or on weekends, except in extreme emergencies.

TEST RESULTS

Please call our office 3-4 days after the date of the test.

BILLING QUESTIONS

All patient billing questions should be directed to our billing service as follows:

• Dr. Delamarter: (310) 322-4278
• Dr. Bae: (310) 322-4278
• Dr. Kropf: (310) 322-4278
• Dr. Rasouli: (310) 322-4278

SCHEDULING APPOINTMENTS Call: 888-774-6376

• Follow-up Appointments  If you are a non-surgical patient, and the doctor requests that you return for a follow-up visit, please be sure to make your return appointment prior to leaving our office or within a week following your original appointment. This will insure your appointment is at a time convenient for you.
• Post-Operative Appointments  Surgical patients need to be seen at a time determined by the doctor. It is recommended that an appointment be made prior to being discharged from the hospital.

PATIENT REQUESTS FOR LETTERS

All letters (i.e. for medical necessity, jury duty, disability status, return to work, etc.) will be completed within 3-5 business days from the date of request.

PATIENT REQUESTS FOR FORMS

• All forms (i.e. disability, insurance, etc.) will be completed within 3-5 days from the date of receipt.
• Note: All portions of the form requiring patient (employee) completion must be completed prior to forwarding the form to the doctor.

PATIENT REQUESTS FOR MEDICAL RECORDS

• We will need a signed authorization from the patient for release of medical records.
• We will accept faxed authorizations (FAX# 310-828-6687)

PATIENT REQUESTS FOR X-RAYS

A patient may sign out his or her X-rays. The patient is fully responsible for the safekeeping and return of the X-rays.

SURGERY

All questions regarding pending surgeries should be directed to
Dr. Delamarter's office, Dr. Pradhan's office, Dr. Bae's office, or Dr. Kropf's office as appropriate.

INSURANCE AUTHORIZATION REQUIREMENTS

• Please be advised that it is the patient's responsibility to obtain the necessary authorizations from their insurance company prior to seeing a doctor. Prior authorization is also required for any plain x-rays that are taken in our office during your visit.
• If we have not received a written approval prior to your appointment, we will require you to make full payment at that time, or your appointment will be cancelled.
• If you are uncertain whether a pre-certification is required, please contact your benefits department. If you are a member of an HMO/HealthNet, you must get prior approval from your primary care physician. The necessary telephone numbers are usually located on the back of your insurance card. If you are a Workman's Compensation patient, you must obtain prior approval from your adjuster.
• If your insurance company/workman's compensation require information from the doctor regarding the need for a visit, please let us know and we will forward the required paperwork.
• Medicare does not require any pre-certification.

FINANCIAL POLICY

We are committed to providing you with the best care possible. In order to achieve this goal we are in need of your assistance and understanding of our financial policy in the following areas:

• Initial Consultation The patient is responsible for any copayments and any unmet deductible amount, due and payable at the time of the office visit. As a courtesy, the office will bill your insurance company, provided you furnish the office with a completed insurance claim form or insurance card. A patient without medical insurance will be required to pay in full at the time of service.
• Initial Consultation (Medicare Patients) Since our office accepts Medicare assignment, we will bill Medicare for you. Patients who have Medicare only, are responsible for the co-insurance portion approved by Medicare. If you have a secondary insurance, we will also bill them for you.
• Physical Therapy It is recommended that all patients in need of physical therapy contact their insurance company to find out exactly what benefits they are entitled to. Medicare restrictions on benefits can be explained by our staff.
• Cancellation of Appointments All cancellations must be made at least 24 hours prior to the scheduled appointment. Patients who are more than 20 minutes late will not be able to see the doctor and will have to reschedule their appointment.
• Workmen's Compensation Must be pre-approved before the patient may receive services.
• Types of Payment Cash, checks, Visa, Mastercard, American Express.

While the filing of your insurance claim is a courtesy we extend to our patients, we must emphasize that as medical care providers, our relationship is with you the patient, not your insurance company. All charges are the responsibility of the patient from the date the services are rendered. We realize that from time to time temporary financial setbacks may affect timely payments on your account. If such problems do arise, we encourage you to contact our office for assistance in the management of your account.

Our Staff will gladly discuss your proposed treatment and answer any question relating to your insurance. However, not all services are a covered benefit in all contracts and you must realize that your insurance is a contract between you, your employer, and the insurance company.

If you have any questions about the above information or have uncertainty reqarding the insurance coverage, please do not hesitate to ask for assistance.