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Start Your Journey

Welcome to our Office Forms page

Think of these forms as the essential tools you need to build a smooth and tailored experience with Dr. Mutafyan. Just like you wouldn’t start cooking without having all the ingredients ready, filling out these forms beforehand ensures that when you come in, we’re fully prepared to focus on you and your unique needs.

This process saves you 2-6 weeks of extra waiting—no need to come in just to fill out paperwork, schedule separate weight loss seminars, or wait while we verify insurance and check your medical history for things like cardiac clearance. By completing the forms now, you’ll be able to step right into a personalized consultation where all options are ready to be discussed. Let’s make your journey as smooth and stress-free as possible!

    PATIENT DEMOGRAPHIC INFORMATION

    Personal Information

    Emergency Contact

    Primary Care Provider

    Preferred Pharmacy

    Assignment of Benefits


    I hereby assign all medical and/or surgical benefits, including Medi-Cal and other government-sponsored programs, private insurance, and any other health plans to Pro-Surgical, Inc./Dr. George Mutafyan’s office. This assignment will remain in effect until revoked in writing. I understand that I am financially responsible for all charges whether or not paid by insurance and authorize the release of necessary information to secure payment.

    Patient Rights and Responsibilities

    You have the right to:

    • Considerate and respectful care, and to be made comfortable. You have the right to medical care that respects your culture, psychosocial, spiritual, and personal values, beliefs, and preferences.

    • Know the name of the physician who has primary responsibility for coordination of your care and the names and professional relationships of other physicians and non-physicians who will see you.

    • Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including anticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care. You have the right to participate in ethical questions that arise in the course of care, including issues of conflict resolution, withholding resuscitative services, and foregoing or withdrawing life-sustaining treatment.

    • Make decisions regarding medical care and receive as much information about my proposed treatment or procedure as you may need in order to give informed consent or to refuse a course of treatment. Except in emergencies, this information shall include a description of the procedure or treatment, the medically significant risks involved, alternate course of treatment or non-treatment and the risks involved in each, and the name of the person who will carry out the procedure or treatment.

    • Request or refuse treatment, to the extent permitted by law. However, you do not have the right to demand inappropriate or medically unnecessary treatment or services. You have the right to leave the physician’s office, even against the advice of the physician(s), to the extent permitted by law.

    • Be advised of the personnel the physician proposes to engage in or perform human experimentation affecting your care or treatment. You have the right to refuse to participate in such research projects.

    • Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions. You may request or reject the use of any or all modalities to relieve the pain, including opiate medications, if you suffer from severe chronic intractable pain. The physician may refuse to prescribe opiate pain medications, but if so, must inform you that there are physicians who specialize in the treatment of severe chronic pain with methods that include the use of opiates.

    • Have personal privacy respected. Case discussion, consultation, examination and treatment are confidential and should be conducted discreetly.

    • Confidential treatment of all communications and records pertaining to your care and say in the physician’s office. You will read a separate “Notice of Privacy Practices” that explains your privacy rights in detail and how we may use and disclose your protected health information.

    • Reasonable continuity of care and to know in advance the time and location of appointments as well as the identity of the person(s) providing the care.

    • Exercise these rights without regard to sex, race, color, gender, religion, ancestry, national origin, age, disability, medical condition, marital status, sexual orientation, educational background, economic status or source of payment for care.

    I hereby acknowledge that I have read and understand my rights and responsibilities as a patient at Pro-Surgical,Inc./Dr. George Mutafyan’s office and of the rules and regulations governing my conduct and responsibilities as a patient.

    JOINT NOTICE OF PRIVACY FOR HEALTH INFORMATION (NPP)
    ACKNOWLEDGEMENT FORM

    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.

    Our Pledge To You

    We understand that medical information about you is private and personal. We are committed to protecting it. Doctors and other staff make a record each time you visit our office or communicate with us. This notice applies to the records of your care, which is created by your physician or the clinical staff of this practice. Your physician and other health care providers may have different practices or notices about their use and sharing of medical information in their own offices or clinics. We will gladly explain this notice to you or your family member.

    We are required by Law to:

    • Keep medical information about you private

    • Give you this notice describing our legal duties and privacy practiced for medical information about you

    • Follow terms of the notice that is currently in effect

    How We May Use And Share Your Medical Information:

    We will use and share medical information about you for purposes of treatment. We will use and share medical information about you in order to receive payment for treating you. We will use and share medical information about you for our healthcare operations. We may contact you for appointment reminders. We may contact you about possible treatment options, health related benefits, or services that you may want. We may share your medical information for research projects, such as studying the effectiveness of a treatment you received. We will report certain medical information for public purposes, such as births, death, and certain diseases to the state. We may also report problems with medicines or medical products to the manufacturer and to the FDA. We may tell you about recalls of products you are using.

    Your Right Regarding Medical Information:

    In most cases, when you ask in writing, you can look at or get a copy of medical information/records about you. Our clinic charges a fee of $50.00 if you wish to obtain a copy of your full medical records. When obtaining your records, they will not be given to anyone other than you. If you believe that information about you is wrong or missing, you can ask us in writing to correct the records. You can ask that medical information be given to you in a confidential manner. You must tell us in writing the exact way or place for us to communicate with you. You can ask in writing that we limit our use or sharing of medical information about you.

    By submitting below, you acknowledge receipt of this notice, as the patient involved in the medical care.

    AUTHORIZATION FOR RELEASE AND SHARING OF YOUR MEDICAL INFORMATION WITH CERTAIN PERSON(S)

    We are required by law to keep your medical information and any treatment plans private. We will not share this information with your family members or friends. If you wish for our provider(s) and anyone involved in our care at this practice to disclose information and speak to, in regards to your health and treatment plans, to another entity other than yourself, we will only do so if we have a written and signed authorization from you, which states the person(s) name with whom you wish our office to contact and disclose information to other than you as the patient.

    Check the box below if you do not wish for your Medical information and any information regarding your care to be disclosed or shared with anyone besides you as the patient.

    Do not disclose any information to othersDisclose or share your information

    If you wish for your information to be disclosed and shared with someone other than you, please complete the following:

    By signing below, I have read and understood this notice and I hereby authorize Pro-Surgical, Inc./Dr. George Mutafyan, MD and his office staff to disclose and share my information and communicate about my medical and surgical care with the individual I have named above. I understand and I will not hold the office accountable for violating any HIPAA laws by disclosing my information and care plan to the individual named above, as I give my full consent for Pro-Surgical, Inc and its providers and staff to do so. In the instance that my decision changes, I will notify the office in writing to discontinue the share of my health information with the individual named above.

    Physician-Patient Arbitration Agreement

    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 disputes 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 intention, of the parties that this agreement bind 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 or patient to collect or contest any medical fee shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any malpractice claims, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

    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 parties 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 anytime 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 check 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 my signature below, I acknowledge that I have received a copy.
    NOTICE: 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.

    FINANCIAL AGREEMENT AND ASSIGNMENT OF BENEFITS FOR ATTENDING AND CONSULTING PHYSICIANS

    Financial Agreement

    The undersigned agrees, whether he/she signs as the patient or as an agent of the patients on the patient’s behalf that in consideration of the service(s) rendered or to be rendered to the patient that he/she hereby individually obligates himself.herself to pay the charges of the undersigned patient's attending and or consulting physician. Should unpaid charges owed to the patient's physician(s) be referred to an attorney or collection agency for collection. The undersigned shall pay the attorney fees and collection expenses actually incurred in collecting the unpaid charges. All delinquent unpaid charges shall also bear interest at the rate(s) provided by law.

    Assignment of Benefits And Authorization to Pay Physicians

    By submitting below, the undersigned also authorize(s) direct billing by the patient’s physician(s) of, and direct payment to the patient’s physician(s) from, any insurance company or other provider or payer of health care benefits to which the patients is entitled for professional services rendered by the patient’s physician(s). This assignment of benefits and authorizations to make payment to the patient’s physician(s) encompasses all benefits to which the patient’s entitled, including health care benefits provided by the medicare program.

    Non-Covered Charges

    By submitting below, the undersigned further agree(s) that he/she will be personally responsible  for payment of any charges of the patient’s physician(s) which are not payable or paid under any insurance or other health benefits to which the patient is entitled; provided that with respect to Medicare benefits the patient’s physician(s) agree(s): (1) The Medicare program’s reasonable charge for the patient’s physician(s) services covered under the Medicare program shall be the full charge for such services, and (2) the patient and/or person financially responsible for the services provided to the patient shall not be personally responsible for any amount more; (a) the amount of any unpaid annual deductible, if any; (b) the amount of the blood deductible, if applicable; and (c ) twenty percent (20%) of the difference between the deductible and the Medicare program’s reasonable charge of the patient’s physician(s) services.

    Disclosure of Information

    By submitting below, the undersigned further acknowledge(s) that pursuant to California Civil Code Section 56.10 (c ) and any successor statue, to the extent necessary to determine liability for payment and to obtain payment, the patient’s physician(s) may disclose portions of the patient’s record, including the patient’s medical records, to any person or corporation responsible for paying for health care services rendered to the patient. Separate written permission will be obtained by the patient’s physician(s) prior to releasing information from the patient’s medical record concerning treatment for alcohol or drug abuse or for treatment of some other condition(s) requiring special disclosure authorization by law.

    Copy of Authorization

    A Photocopy shall be made of this form as executed, and that copy shall become a business record of patient’s physician(s).

    The undersigned certifies that he/she has read the foregoing and is the patient,the patient’s legal representative, or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.

    Non-Discrimination Policy

    This clinic, Pro-Surgical, Inc. issues this notice to remind patients, providers and healthcare staff, that under federal law, it is prohibited to illegally discriminate patients the basis of sex, race, color, religion, ancestry, national origin, language capabilities, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, living conditions, gender, gender identity, or sexual orientation. The clinical and administrative staff have a duty to stay abreast of California's anti-discrimination laws, adopt workplace policies and procedures that are in line with these laws. All staff at this practice are required to undergo discrimination awareness and prevention training.

    Pro-Surgical, Inc.:

    • Provides free language services to people whose primary language is not English, by providing qualified interpreters during phone conversation and appointments, in addition to written communication in other languages.

    • Provides aid to set up transportation services for individuals with physical disabilities or individuals who have an inability to transport to necessary appointments.

    If these services are needed, patients must request the services at least one week prior to scheduled appointments for the necessary accommodations to be made in a timely manner. These services are only provided during official business operating hours during Monday to Friday 9:00 AM to 5:00 PM. To protect patient privacy laws and comply with HIPAA laws, this practice does not share information or request services from any non-contracted or non-health care certified entities that provide language or transportation services. Under practice policy and patient privacy and safety procedures, the clinical or administrative staff  does not go to patient’s preferred or requested locations including vehicles, place of residence, place of employment, or  place of education.

    Non-Harassment Policy.

    Any unwelcomed behavior, verbal or non-verbal, including jokes, insults, and innuendoes; threats; degrading sexual remarks; intimidating or confrontational body language, photography without an individual’s permission, racist or other derogatory remarks and behaviors, violent behavior, or any physical altercation will not be tolerated at this clinic as we thrive to make the treatment environment for all patient and staff safe.

    No Show and Cancellation Policy and Procedure

    Policy Description:

    Pro-Surgical Inc, does not charge patients for missed appointments including Pre-operative assessment appointments, follow up visits, consultations and office procedures. However, for any major surgeries that are coordinated with major hospitals and ambulatory Surgery Centers are subject to the cancellation policy. Pro-Surgical, Inc staff organizes a surgery date by discussing the surgery date with the patient prior to scheduling and getting confirmation from the patient via electronic or verbal communication. The surgeries are scheduled with respect to allow the patient(s) enough time to coordinate with their personal schedules and agendas. Once the surgery is scheduled, the patients are given a pre-operative assessment appointment at the clinic which is one-three weeks before the scheduled surgery date. If a patient canceled their scheduled surgery without formally notifying the scheduling team two weeks before the scheduled day, they will be subject to the cancellation fees.

    Exceptions:

    Patients who are critically ill, are involved in motor vehicle accidents, sudden onset of major and hindering medical issues that occur between the two weeks before the surgery date, and an exception to this policy. Any Patient who receives a notice of contraindication for surgery from any other providers involved in their care, including the surgeon and/or the facility, and any uprising insurance or changes, or termination of health benefits, will be an exception to this policy and its fees.

    Cancellation Charges:

    Patients who fail to show for their scheduled surgery appointments and do not notify the office at least two weeks prior to their surgery date, shall be subject to the cancellation charge of $550.00. These charges are not covered by the insurance to which the patient is entitled to, therefore the patient is solely and personally responsible for the cancellation fees.

    I hereby acknowledge that I have read and understand the Pro-Surgical, Inc. cancellation policy and its procedures. I understand that these fees are non-refundable and I am personally responsible for the payments.

    CONSENT FOR USE OF PHOTO AND VIDEO

    Videos and photographs may be used with respect to HIPAA laws. The photographs and videos may be used for research purposes, social media, evaluation of treatment or disease progression, and determining treatment plans. The photographs and videos will be obtained in a professional manner and shall be used for the purposes within this medical practice. Patients have the right to refuse or grant the use of photographs, videos, and are permitted to alter their decision by signing this form at any time during their care at this office. If the Pro-Surgical, Inc. uses the obtained photographs and/or videos, it will notify the patient(s) before doing so, the patient will be provided with the purpose(s) of the use of the material prior.

    Grant permission for photo and video useDo NOT grant permission for photo and video use

    I hereby grant permission and give consent to the release and use of photographs, electronic media for presentation. I understand that the images may appear on company websites and social media including advertisements, leaflets, brochures, and posters managed by the owner of the business or its authorized representative(s). The photographs and videos shall not be used for any other purpose(s). The obtained media will not include personal information and are subject to copyright.

    Weight Loss History



    History of Weight Loss Programs, Diets, and Medications



    Weight and Height Information




    Taste Preferences


    Eating Habits


    Medications






    Previous Surgeries and Medical Diagnoses




    Family History


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    Obesity-Related Conditions


    Habits




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    GLENDALE,CA 91205

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