Forms

Dr. Sajben specializes in complex intractable pain, treatment resistant Major Depressive Disorder, Bipolar Depressed and Juvenile Bipolar Disorder.

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If you are unable to view and print pdf files below, you will need this free Adobe Acrobat Reader.

If you have difficulty downloading the Reader, please notify me.

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UNLESS REFERRED BY LOCAL PHYSICIANS

DOCTOR SAJBEN IS NO LONGER ACCEPTING NEW PATIENTS

 

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Bring the following to your first appointment:

  • bottles of all your medications, bottles of vitamins and supplements so that I can read the labels
  • medical insurance card
  • completed forms#1 through #6 – the original forms filled out in black or blue ink, not use marker pen or staples. Do not fax. Print single sided.
  • I do not accept Worker’s Comp or litigated cases and not Medicare Advantage (which is like HMO).
  • Payment in full is required at time of visit for PPO or uninsured patents.  I do not accept credit cards. Check or cash is accepted. I accept Medicare or Tricare.
  • You are encouraged to bring your medical questions and concerns to discuss them with me. Family members and friends are strongly encouraged.
  • Note instructions for constipation and dry mouth on this page (below forms).

1. Instructions first visit (pdf)

2. Release of records (pdf) Do this first. Scripps & many places need form sent to MEDICAL RECORDS department, not to your doctor. Allow doctors time to get the records to me or that may delay treatment. Bring a copy of the signed and completed release forms to your visit, include one blank form signed but not completed – we may need it.

3.  Demographics (pdf)

4. Medications (pdf)  this form is important – include supplements and vitamins.

It is not necessary to duplicate this information on the next form.

5. Medical History (pdf)

6. Brief Pain Inventory – First Visit (pdf)  – This form for is only for those who have pain. That includes persons with Major Depression who also have pain. I do need to assess.

7. Print this page MAP & Directions.

View Google Map & Directions at top of this site for photos & links.

By printing the above forms and bringing only the above forms to our first visit, there is no need to print the HIPAA form below unless you wish to keep a copy.

HIPAA Patient Privacy Notice (pdf)  If you have family or friends you would like me to be able to advise at any time, please list their names and relationship to you on a separate sheet titled HIPAA Privacy. Otherwise, if you are too ill to communicate, I cannot give them any information or let them know I see you.

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Please do not fax the above forms to me. I need the originals.

Payment is requested at the time of visit. I do not accept credit cards. I do accept Medicare and Tricare as a courtesy, and will electronically bill for services.

Before you call this office, you may wish to call your PPO insurer and ask what they reimburse for an “out of network” doctor for these billing codes:

99205 – initial patient evaluation (1 hour). For complex cases, this may be 3 hours. If longer than one hour, PPO will only reimburse for 1 of 3 hours and they will give a % of what they think MD’s charge, not what I charge.

99215 – return visit (40 min)

Keep in mind if you have a complex condition, your visit will last longer than one hour and time will be billed accordingly or may need to be rescheduled for several reasons: complexity, contributing medical and/or psychiatric conditions, failure to obtain medical records, substance abuse issues, after hours, reports.

I am generally available to my patients Pacific Standard Time late afternoons, evenings, weekends, holidays—not mornings. I am in the office on Tuesdays and Thursdays. I interview all patients telephonically to determine if appropriate for my practice, but my current patients always come first and at times that may delay my ability to return new patient requests for 2 or 3 days.

If your Major Depressive Disorder or Bipolar depression is a crisis, please call 911 or go to the nearest emergency room – do not call me for a first appointment. I am not a psychiatrist. I will work with your psychiatrist and consider seeing you after your mood has stabilized.

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I look forward to meeting you and helping you and your family on this journey to improve and function.

Warm regards,

Nancy L. Sajben MD

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Return visits only

Pain Care Progress Note (doc) 103 KB —- use font Ariel 10 point to fit on one page. You can save this form on your computer, fill in your medications on the form you just saved, print and reuse it – but keep it updated on medication changes. That will save you from having to rewrite them each visit.

Pain Care Progress Note (pdf) 108 KB — This version of the above form will fit on one page. You are unable to list medications on this page with computer. Instead, complete form and fill in medications with pen.

Log (pdf)

Neuropathy Pain Scale (pdf)

Dry Mouth & Thick Saliva, Saliva Substitutes(pdf)

Constipation (pdf)

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Return to home page:  Welcome to my Weblog on Pain Management!

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