NEW PATIENT PACKET 

 

Thank you for choosing Webster Orthopedics for your medical needs. To prepare 

for your first visit with us, we have provided a new patient checklist to get you 

ready for your visit.  

 

Completed New Patient Packet, enclosed.  Photo Identification   Current insurance card(s)   Co‐pays and any out of pocket expenses are collected at the time of service.  Medical records and medical record diagnostics: Xrays, MRI, CT, EMG scans on CD/Hard film, if applicable. 

Primary Care Physician, referring doctor, name, address, phone and fax number. This allows us to coordinate care, if appropriate. 

Pharmacy name, address, and phone number.  

We thank you in advance for having these items prepared prior to your arrival. 

We look forward to having you as our patient. 

       

1‐800‐943‐8099 www.WebsterOrthopedics.com 

NO KNOWN DRUG ALLERGIES

Novocain etc. Penicillin Ke�ex Erythromycin Other antibiotic: ________________________

Sulfa drugs Aspirin □ Morphine □ Percocet □ Oxycontin□

Latex Eggs/Yolk Sul�tes Tetracycline Iodine/shell�sh Ibuprofen etc

Please specify any others:

Please specify type of reaction:

Occupation___________________________________Employer____________________________________

Marital Status ________________________________

Lives with (check all that apply):

Spouse Children Parents Mother Father Grandparents Foster Care Roommates

Tobacco - Do you smoke or use tobacco products?__________ Check all that apply: Cigarettes Cigars Chewing Tobacco

Recreational Drugs-Do you use recreational/illicit drugs?___________ Which drugs? _________________________

Exercise-Do you exercise on a regular basis? Yes No Type of Exercise: ________________________________

Times per week: _________________

Experience. Excellence.

Medicines

Drug Allergies

Social History:

Social Habits:

Codeine Other painkillers

(V042017)

Have you experienced any of the following in the last few weeks of months?

Please check the complaint and detail below. If you have no complaints in the category, please check:

Gastrointestinal:

General: Eyes/Ears/Nose/�roat

Genitourinary:

FeverChillSweatsFatigueDi�cultty SleepingWeight LossWeight Gain

GlassesContactsDouble VisionImpaired HearingRunny NoseNosebleedsSneezingDenturesDizziness

Respiratory:Cardiovascular:CoughColdWheezingPainful BreathingTuberculosis

Chest PainsFaintingLeg SwellingShortness of BreathMurmur

NauseaVomitingConstipationLoose StoolsBlood in StoolsAbdominal Pain

Musculoskeletal: Other:Back PainNeck PainJoint PainJoint SwellingMuscle CrampsMuscle WeaknessSti�ness

Past Medical History:AnemiaArthritisAsthmaCancerCOPDDepressionDiabetes Type 1Diabetes Type 2EsophagealGoutHeart DiseaseHepatitis AHepatitis BHepatitis CHiatal Hernia

Family Medical History:Patient denies any signi�cant Family HistoryAnesthesia/ Surgical ComplicationsAsthma/Breathing ProblemsBleeding DisorderBlood Clots/PhlebitisCancerCardiovascular DiseaseConnective Tissue DisorderCOPD Chronic Obstruction Pulmonary DiseaseDiabetes GoutHeart Disease/Heart Attack/Chest PainsHepatitis/Liver DiseaseHigh Blood PressureHigh CholesterolMuscular DystrophyOsteoarthritisOsteoporosisRheumatoid ArthritisStrokes/ Transient Ischemic Attacks (TIA)�yroid Disease

HypercholesterolemiaHypertensionKidney DiseaseLiver DiseaseOsteoarthritisOsteoporosisStroke�yroid DiseaseTuberculosisPneumonia

Urine IncontinenceUrinary FrequencyBlood in Urine

Neurological:WeaknessNumbnessParalysisLoss of ConsciousnessHeadacheTremorSlurred Speech

Skin:Open SoresBoilsWound BreakdownTender SpotRash

Endocrine: Psychiatric:FatigueHyperactivityExcessive �irst

DepressionAnxietyMemory LossMood Swings

Allergic/Immunologic:HivesPersistent InfectionsHIV ExposurePast Blood Transfusion

Heme/Lymphatic:BruisingBleedingLymph Node Swelling

Pregnancy- Estimated Due Date:

Review of Systems:

(V042017)

Have you or a family member ever been diagnosed with a blood clot in a leg or lung? YES NO

If “YES”, who had the clot?

Are you under the care of a Cardiologist?: YES NO

Name:

Contact Info:

Have you ever had problems with Anesthesia in the past? YES NO

If YES, please explain:

Previous Hospitalizations?

Please list Surgeries/Complications/Diagnoses along with the DATESurgery Year Complications

1.

2.

3.

4.

Have you had an In�uenza shot this year?

For future of�ce visits: Have there been any changes to your personal information, allergies,medication or surgical history?

NO YES (explain) Date: Initial:

PatientSignature: Date:

Do you have any Advanced Care Directives?

If yes, please give the name of your Power of Attorney or Surrogate Agent________________________

YES NO

YES Date:______________________ NO

(V042017)

If Over 65 Years Old:

Fall Risk Assessment:Ambulation: Normal Unsteady Needs assistance (cane, crutches, etc.) Unable to walk

Have you fallen in last 12 months? YES NO

If so how many times? __________ Did it result in an injury? YES NO

Experience. Excellence.

(V042017)

Aching

Burning

Dull

Heaviness

Joint Locking

Loss of Motion

Numbness

Radiating

Sharp

Stinging

Swelling

Tingling

Weakness

Please “X” pain description:

Pain Level: (circle)

 Patient Information  

Patient Full Name: 

☐ New Patient     ☐ Existing Patient 

Date of Birth:        Gender:     ☐ Male     ☐ Female 

Social Security #:      Ethnicity/Race: 

Local Address:          Apt#: 

City:        State:      Zip: 

Primary Phone:       ☐home ☐Cell ☐Work

Secondary Phone:      ☐home ☐Cell ☐Work

Email Address: Given email addresses may be used by Webster Orthopedics and relevant medical affiliations

How did you hear about us?: ☐Employer ☐Social Media ☐Search Engine ☐Insurance ☐Patient

☐Physician ☐Webster website ☐Yelp ☐HealthGrades ☐Magazine

Marital Status: ☐Child ☐Single ☐Married ☐Divorced ☐Widowed

☐Separated ☐Domestic Partner

Employment Status: ☐Full-time ☐Part-time ☐Seasonal ☐Retired ☐

Unemployed ☐Student/self Spouse Full Name: Permanent Address (other than local): City: State: Zip: Primary Care Physician: Referring Physician: Employer:

Emergency Contact Name: Relationship to patient: Primary Phone #: City: State:

Patient/Legal Guardian of Minor or Incapacitated Adult Only Full Name: Date of Birth:

Relationship: Contact #:

 

 

                                 Patient Registration       

Insurance Subscriber Information 

Complete Only if NOT the patient           Insured Subscriber’s Full Name: 

Subscriber’s Date of Birth: 

Subscriber’s SSN: 

Subscriber’s Relationship to Patient: 

Subscriber’s Permanent Address:        Apt#: 

City:        State:                     Zip: 

Primary Phone:         ☐home ☐Cell ☐Work Secondary Phone:      ☐home ☐Cell ☐Work

Subscriber’s Employer:

Complete Insurance Details Insurance Company: Type: ☐HMO ☐PPO ☐Medicare ☐Medicaid ☐Tricare

☐ Workers Compensation ☐Private Pay(no insurance) ID/Policy/claim#: Group#:

Copay/Coins/Ded amount: Effective date:

If work comp: Date of Injury:

Nurse Case Manager’s Name: phone:

Adjuster’s Name: phone:

Do you have an attorney? ☐Yes ☐No if so, who?

Secondary Insurance? ☐Yes ☐No Name:

Secondary Insurance Subscriber: ☐Same as above ☐Self

Signature Signature: Date:        

PATIENT NAME __________________________________________BIRTHDATE:_________________

PATIENT:

________________________________________ _________________ ____________________________Signature of Patient or Legal Representative Date Witness Signature

Relationship to Patient ____________________________________

I understand that The Notice of Privacy Practices information serves as:• A basis for planning my care and treatment.• A means of communication among the many healthcare professionals who contribute to my care.

• A source of information for applying my diagnosis and surgical information to my bill.• A means by which a third-party payer can verify that services billed were actually provided.• A tool for routine healthcare operations such as assessing care quality and reviewing the competence

of healthcare professionals.

Please refer to “Notice of Privacy Practices” Brochure, refer to the “Request Restrictions” section.This brochure is available in the of�ce or online at www.websterorthopedics.com/privacy-policy.

Please answer the following 3 questions:I request the following restrictions to the use or disclosure of my health information:

Detailed messages regarding test results can be left on answering machine

Yes Phone Number ______________________No

Webster Orthopedics utilizes an automated appointmentreminder system. Please choose how you would like toreceive the reminder.

Automated voice messageTextNone of the above

Medical Information can be discussed withPatient onlyFamily member or friendPlease List Name/Relationship

______________________________

______________________________

______________________________

______________________________

______________________________

Physician _______________________________Other __________________________________No RestrictionsOther Restrictions__________________________________________________________________

2#1#

#3

CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATIONFOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

Experience. Excellence.

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment.

o Including said healthcare professional obtaining medical history from the patients’ pharmacy, health plans, and other healthcare providers.

(V042017)

Patients Name______________________________________________________________________________

MEDICARE PATIENTS ONLY

LIFETIME BENEFICIARY AUTHORIZATION

I request payment of authorized Medicare benefits be made either to me or on my behalf to Webster Orthopedics for any service furnished me by that 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 payable to related service.

I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim form is completed, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

Authorization to Obtain Medication History

By signing below, I hereby authorize Webster Orthopedics to obtain Medication History related to the patient above, from Community Pharmacies and /or Pharmacy Benefit Managers for the purpose of Continued Treatment.

Date:__________________________

Patient/Legal Representative or Parent/Legal Guardian Print Name___________________________________

Patient/Legal Representative or Parent/Legal Guardian Signature_____________________________________

Experience. Excellence.

(V042017)

MRI Disclosure: Certain diagnostic tests such as MRI include both a professional component (representing the physician’s interpretation of the test) and a technical component (representing the test itself). Webster Orthopedics shall bill Medicare Part B directly for the technical component of diagnostic services while the Radiologist, California Advanced Imaging, bills Medicare for the professional component. You may receive additional correspondence from California Advanced Imaging in the form of an explaination of benefits (EOB) or other document.

Experience. Excellence. Webster Patient Notifications

Workers Compensation Medication Notification:

Please note you have a choice between obtaining the prescriptions from our office or have us provide youwith a prescription to be filled at a pharmacy of your choice. _____Patient Initials

Physician Assistant Consumer Notification:

Physician Assistants are licensed and regulated by the Physician Assistant Committee(916) 561-8780 www.pac.ca.gov _____Patient Initials

Notice Regarding Disclosure of Physician Ownership Interests:The following physicians: Joshua C. Richards, MD; Kevin M. Roth, MD; Aaron K. Salyapongse, MD; J. Theodore Schwartz Jr., MD; Eric S. Stuffmann, MD; Michael D. Tseng, MD; Stephen R. Viess, MD hold ownership interest in the following and may refer you to one or more of these services in connection with your care and treatment:

Please note that you have the right to obtain MRI services, medical devices or physical therapy from anyprovider of your choosing unless your ability to choose the providers of such services is limited by theterms of your health insurance coverage.

The following is a nonexclusive list of five other MRI providers located within the general area of Dublinand San Ramon and Oakland.

• Alliance Imaging, 6001 Norris Canyon Road, San Ramon CA 94583 (925)-275-0634• Golden View Imaging, 1393 Santa Rita Rd, Pleasanton CA 94566 (925)-846-5888•••

Pleasanton Imaging, 5860 Ownes Dr., #150, Pleasanton, CA 94588 (925)-467-1400

Date: ______________________________________________________________

Patient Name(print): __________________________________________________

Patient Signature: ____________________________________________________

Signature of Parent or Guardian: ________________________________________

*Castro Valley Open MRI*East Bay Ortho Co Management*East Bay Special Surgery*Fremont Surgery Center*Hand Therapy Clinics*High Field MRI in Dublin/Pleasanton*Oakland High Field MRI*Open MRI of San Ramon*Nor Cal Surgery Center

*Pleasanton Surgery Center*Redwood Surgery Center*San Ramon Surgery Center*Sports Physical Therapy in San Ramon*The Surgery Center of Alta Bates*Webster Wellness Center in Berkeley*Webster DME distribution*Webster Surgery Center(Castro Valley, Oakland & Pleasanton)

Alta Bates Summit Medical Center-MRI Center, 5730 Telegraph Ave., Oakland, CA 94609 (510) 654-5855NorCal Imaging, 3200 Telegraph Ave, Oakland, CA 94609 (510) 663-1950

(V122017)

Joseph R. Donnelly, MD; Andrew Hou, MD; Thomas W. Peatman, MD;

Webster Financial Policy

CASH: Please note: New P ent Deposit of $311.00 and Established P ent Deposit of $150.00 Payment Op ons:

will be required prior to being seen by the provider. At the end of your visit, the total cost of your services will be calculated to determine if addi onal money is due from you or if you will receive a refund. Your service will be totaled out and we will either collect the remaining balance or refund you the credit.

COPAYMENT: As required by your insurance company, copayment is required at the me of service. If you are unable to pay your copay at the me of service, your visit may be rescheduled. If your visit is accommodated, there will be a $5 service fee for all processed co-payments.

COINSURANCE: If your insurance assigned a coinsurance percent instead of a copay amount (listed on your card i.e. 20%), we will collect that es mated percentage. We collect $10 for every 10% coinsurance, $20 for every 20% coinsurance etc. Since this is only an es mate, you may owe more once your insurance carrier processes your claims.

CREDIT CARDS: Visa, MasterCard and American Express are accepted. Debit Cards are accepted for all Banks.

CHECKS: Checks are accepted but please note that a return check fee of $35 will be charged on all returned checks. Cash or credit card will be required for future payments.

SURGERY: In the event you are scheduled for surgery, we will verify your insurance benefits and n fy you of your es mated co-insurance and/or deduc ble amounts. These amounts will be collected prior to your surgery date and will be applied to the surgery balance and/or any outstanding balances. Please note that you will receive separate bills from providers outside of Webster Orthopedics such as for anesthesiology, surgery center facility fees and durable medical equipment items.

We bill your insurance as a courtesy to you. In order to do so, we require your current insurance inform on and a copy of your insurance card. We also require your social security number for our records. Your financial records and your health care records are kept confiden al and secure. If you choose to not give your social security number, you will be required to pay the cash pay deposit amount of $311.00 in order for us to file your insurance claim. Once your insurance pays we will issue any applicable refund or bill any remaining balance.

Insurance Billing Policies:

It is your responsibility to make sure the insurance we have on file is the most current. Any claim that needs to be resubmi w insurance, incomplete or outdated inform on may incur a $25 administr ve refiling fee.

Medicare: We accept assignment with Medicare. One secondary insurance claim will be filed as a courtesy.

Non Contracted Plans: We submit one insurance claim as a courtesy. A er 30-days the balance is pa ent responsibility.

Experience. Excellence.

(V082016)Page 1 of 2

Motor Vehicle Claims: We submit one insurance claim as a courtesy. A er 30-days the balance is p ent responsibility.

Third Party Claims: We DO NOT bill third party claims.

HMO/Medical Group Plans: A referral is required from your Primary Care Physician prior to each appointment. If you do not have an authori on or referral, you may be required to reschedule or sign a waiver s ng you will be responsible for any denied services.

Worker’s Compensa on: It is your responsibility to inform Webster Orthopedics that your care is for a work-related injury. If the claim is DENIED or closed 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. A deposit may be required in order to dispense these products to you. A er the insurance processes your claim, the deposit is applied and you become responsible for any unpaid residual balance. Please note, these charges may be reflected on your bill from Webster Orthopedics or you may receive a separate bill from Breg. (Our DME vendor)

Administra ve Fees:

Delinquent Accounts: Any account that is unpaid for more than 60 days will be considered delinquent unless you have signed a payment agreement with Webster. Those accounts considered delinquent will be forwarded to an outside collec on agency which will impact your credit ra ng. If your account is past due and considered delinquent, we may be forced to suspend all but emergency care un l payment is received. Please contact the billing office to discuss any issues you may be having at 925-314-8460.

My signature indicates that I have read, understand and agree to the Financial Policy of Webster Orthopedics.

Pa ent/Guardian Signature________________________________________Date__________________________

Pa ent/Guardian Printed Name ____________________________________P ent’s Date of Birth_____________

(V082016)

-There will be a $25.00 no-show charge assessed for any appointment that is not cancelled within a 24-hour period prior to the appointment date and time.

-Form Comple on Fee: $15.00 -Diagnostic Images: CD Fee $5.00; Analog Fil m $10.00 per sheet.-Medical Records $15.00 (1-50 pages); 51+ pages = $15 + 0.25pp; plus CA sales tax & USPS postal rates (based on package weight). CD Fee: $5.00.

-Physical Therapy will charge an $80.00 no-show fee for any initial evaluation and a $50.00 no-show fee for any follow up evaluation appointment that is not cancelled within a 24-hour period prior to the appointment date and time.-MRI will charge a $50.00 no-show fee for any appointment that is not cancelled within a 24-hour period prior to the appointment date and time.

Page 2 of 2

Experience. Excellence.

Request Amendment. You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and your reasoning that supports your request.

We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if: - the information was not created by us, or the person who created it is no longer available to make the amendment; - the information is not part of the record which you are permitted to inspect and copy; - the information is not part of the designated record set kept by this practice; or if it is the opinion of the health care provider that - the information is accurate and complete.

Request Restrictions. You have the right to request a restriction or limitation of how we use or disclose your medical information for treatment, payment, or health care operations. For example - you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing to our practice manager.

We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will comply with your request unless that information is needed for emergency treatment.

An Accounting of Disclosures. You have the right to request a list of the disclosures of your health information we have made outside of our practice that were not for treatment, payment, or health care operations. Your request must be made in writing and must state the ti me period for the requested information. You may not request information for any dates prior to April 14, 2003 (the compliance date for the federal regulation) nor for a period of time greater than six years (our legal obligation to retain Information).

Your first request for a list of disclosures within a 12-month period will be free. If you request an additional list within 12-months of the first request, we may charge you a fee for the costs of providingthe subsequent list. We will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred.

Request Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. For example - you may request that we call you only at your work number, or by mail at a special address or postal box. Your request must be made in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests.

File a Complaint or for More Information. If you believe we have violated your medical information privacy rights, you have the right to file a complaintwith our practice manager or directly to the Secre-tary of Health and Human Services.

To file a complaint, you must make it in writing within 180 days of the suspected violation. Provide as much detail as you can about the suspected violation and send it to Privacy Officer, c/o Webster Orthopedics, 200 Porter Street, Suite 215, San Ramon, CA 94583. You should know that there would be no retaliation for your filing a complaint.

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose healthinformation about you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation.

Uses or Disclosures Not Covered

Effective Date: 04/14/03

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.We are required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your protected health information and we also describe them in this notice.

NOTICE OF PRIVACY

PRACTICES

Experience. Excellence.

4000 Dublin Blvd., Ste. 100Dublin, CA 94568PH: (925) 556-7320FAX: (925) 479-0231

5801 Norris Canyon Rd, Ste. 210San Ramon, CA 94583PH: (925) 355-7350FAX: (925) 244-1455

3315 Broadway, Street LevelOakland, CA 94611PH: (510) 486-2300FAX: (510) 486-2333

19842 Lake Chabot RoadCastro Valley, CA 94546PH: (925) 556-7320FAX: (925) 479-0231

Ways in Which We May Use and Disclose Your Protected

Health Information:

The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each category but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health infor-mation fall within one of these categories.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Addition-ally we may from time to time disclose your health information to another physician who we have requested to be involved in your care. For example - we would disclose your health information to a specialist to whom we have referred you for a diagnosis to help in your treatment.

Payment. We will use and disclose your protected health in formation to obtain payment for the health care services we provide you. For example - we may include information with a bill to a third-party payer that identifies your diagnosis, procedures performed, and supplies used in rendering the service.

Health Care Operations. We will use and disclose your protected health information to support the business activities of our practice. For example - we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for our practice.

Other Ways We May Use and Disclose Your Protected

Health Information:

Appointment Reminders. We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment.

Treatment Alternatives. We will use and disclose your protected health information to tell you about or to recommend possible alternative treatments or options that may be of interest to you.

Others Involved in Your Care. We will use and disclose your protected health information to a family member, a relative, a close friend, or any other person you identify that is involved in your medical care or payment for care.

Research. We will use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

As Required by Law. We will use and disclose your protected health information when required to by federal, state, or local law. You will be notified of any such disclosures.

To Avert a Serious Threat to Public Health or Safety. We will use and disclose your protected health information to a public health authority that is permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Worker’s Compensation. We will use anddisclose your protected health information for worker's compensation or similar programs that provide benefits for work-related injuries or illness.

Inmates. We will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care: to protect the health and safety of others: or for the safety and security of the correctional institution.

Your Health Information Rights

Although your health record is the physical property of the health care practitioner or facility that compiled it the information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy.

Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information.This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. Any psycho-therapy notes that may have been included in records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medicalinformation, you must submit your request in writing to our Privacy Officer, c/o Webster Ortho-pedics, 200 Porter Street, Suite 215, San Ramon, CA 94583. You may mail in your request or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.