Patient Record of Disclosure.
In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided and right to request confidential communication or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individual’s home.
Please note that because of COVID-19, we are attempting to keep our office as contactless as possible. Therefore, please consider consenting to receive email correspondence so that we might be able to email any pertinent information, correspondence, and billing statements to you in a paperless fashion.
REVIEW OF NEW SYMPTOMS
Please indicate if you have any of the following symptoms if they are NEW
GENERAL: Weight gain (unintentional) / weight loss (unintentional) / loss of appetite / fever / diminished activity / fatigue
EARS/NOSE/THROAT: Pain / discharge / hearing loss / sinus pressure / drooling / facial swelling / congestion / sore throat / hoarseness / mouth lesions
CARDIOVASCULAR: Chest pain / rapid heart rate
RESPIRATORY: Cough / wheezing / chest tightness / pain with breathing / rapid breathing / difficulty breathing / sleep apnea
GASTROINTESTINAL: Difficulty swallowing / abdominal pain / nausea / vomiting / diarrhea / constipation / blood in stools / mucus in stool
MUSCULOSKELETAL: Soft tissue swelling / joint swelling / muscle pains / limited motion / trauma
SKIN: Pain / itchiness / dry skin / flaking / redness / rash / diaper rash / hives / skin lesions / skin growths / skin lumps / bruising
NEUROLOGIC: Numbness / weakness / tingling / burning / shooting pain / headache / dizziness / loss of consciousness / seizures
PSYCHIATRIC: Depression / anxiety / insomnia / stress / loss of interest
ENDOCRINE: Increased thirst / increased drinking / temperature intolerance / prominent eyes
BLOOD/HEMATOLOGIC: Easy bleeding / easy bruising / frequent nose bleeds
EYE: Pain / blurry vision / redness / itchiness / swelling / discharge / double vision
AUTHORIZATION TO USE SURESCRIPTS, INC.
1. I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: in accordance with New Jersey State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
2. Lee Aesthetic Center, LLC uses SureScripts, Inc., a prescription system that allows prescriptions and related information to be exchanged between my providers and the pharmacy. The information sent between these systems may include details of any and all prescription drugs I am currently taking and/or have taken in the past. This information will be utilized to Lee Aesthetic Center, LLC.
3. This authorization may include disclosure of prescription information related to alcohol and drug abuse, mental health treatment, and/or confidential HIV related information by SureScripts, Inc. to Lee Aesthetic Center, LLC.
4. I have the right to revoke this authorization at any time by writing to Lee Aesthetic Center, LLC. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
5. Signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
6. Information disclosed under this authorization might be re-disclosed by the recipient, and this re-disclosure may no longer be protected by state or federal law.
7. This authorization expires one year from the date of my signature below.
THIS AUTHORIZATION DOES NOT AUTHORIZE LEE AESTHETIC CENTER, LLC TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THOSE PERMITTED UNDER APPLICABLE LAW.
TELEMEDICINE CONSENTTelemedicine involves the use of electronic communications (telephone, computer, etc.) to enable health care providers (doctors, nurses, physician assistants, and others) at a different location from the patient to share medical information with that patient for the purpose of improving access to patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:• Patient medical records• Medical images• Live two-way audio and video• Output data from medical devices and sound and video files
The electronic systems used will attempt to incorporate security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against corruption.
Possible Risks:As with any medical procedure, there are risks associated with the use of telemedicine. These risks include, but may not be limited to:
PATIENT’S ACCEPTANCE OF RISKSBy signing this form, I understand that:
Consent. By signing below, you consent (agree) that:
FINANCIAL POLICY STATEMENT
Your insurance plan is a contract between you and your health insurance company. It is your responsibility to know your benefits and the limits of your coverage. We ask that payments, including any applicable deductible, co-payment, or co-insurance, be made at the time of service unless other arrangements have been made in advance. For your convenience, we accept cash, check, money orders, debit cards, Venmo, and most credit cards. After we submit your claim to your insurance company, your insurance company may state that you owe more than what was collected or calculated previously. We will then bill you for any remaining balance. Any overpayments will be refunded.
Patients with HMO or POS Insurance: If you are a member of an HMO or POS plan, you may need to have a valid referral from your primary medical doctor for each office visit and surgical procedure. Prior to your visit, please call in advance to ensure that all necessary forms and authorizations are in place. Without a valid referral, financial responsibility will lie upon the patient, and full payment will be due at the time of service.
Late Payments: It is our policy to render periodic statements for services on a monthly basis. We reserve the right, at our option, to charge interest on outstanding balances beyond 2 months at a rate of 5% per month. All balances 3 months past due will be sent over to a collection agency and a 25% collection fee will be added to the outstanding balance. In case of credit card disputes, we reserve the right to submit this financial agreement as proof of contract for the financial responsibilities as outlined above.
Returned Checks: Returned checks will incur an additional $35 fee.
No show Policy: In order to be respectful of the medical needs of other patients, please be courteous and call or email the office promptly if you are unable to attend an appointment. A "no-show" is someone who misses an appointment without calling 24 hours in advance to cancel. "No-shows" inconvenience those individuals who need access to medical care in a timely manner, as well as the physician.
A failure to show up at the time of a scheduled appointment or canceled within 24 hours will be recorded in the patient's chart as a "no-show". A credit card authorization form and charge for a $50 rescheduling fee will also be required in order to schedule another appointment. If a patient accumulates 3 “No-shows”, the patient may be asked to leave the practice.
Diagnostic Testing: I understand that, in addition to the examination, there may be diagnostic tests (e.g., visual field test, tear duct system probe and irrigation, CT and MRI scans, labs, biopsy/pathology specimens, etc.) and photographs taken as part of my evaluation. These are performed to help in the diagnosis and management of medical conditions. I understand that, as a result, there may be additional out-of-pocket costs, as dictated by my insurance coverage.
PATIENT AGREEMENT AND AUTHORIZATION
I hereby authorize Lee Aesthetic Center, LLC, its Doctors, and/or agents to apply for reimbursement benefits on my behalf for services rendered to me. I understand that payment from my insurance carrier will be made directly to Lee Aesthetic Center, LLC. I further authorize the release of any information necessary to process any claim with my insurance carrier. I understand that I am financially responsible for all charges, including co-payments, deductibles, and charges for non-covered services by my health insurance. I further understand that I will be responsible to pay for any service denied by my insurance company. In case of credit card disputes, I understand and accept that Lee Aesthetic Center reserves the right to submit this financial agreement as proof of contract for the financial responsibilities as outlined above. I permit a copy of this authorization to be used in place of the original.
I have read and understand the payment policy above and agree to abide by its guidelines.
MEDICARE AUTHORIZATION (DISREGARD IF YOU DO NOT HAVE MEDICARE)
All Medicare patients must sign lifetime beneficiary claim authorization: I request that payment of authorized Medicare benefits be made either to me, or on my behalf, to Lee Aesthetic Center, LLC, and/or Dr. Henry Lee for any services furnished me by that physician. 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 or the benefits payable to related services. I understand my signature requests that payment be made, and authorizes release of information necessary to pay the claim. If other health insurance is indicated in Item 9 of the electronically submitted claims, my signature authorizes release 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 deductibles, copays, and non-covered services. Co-insurance and the deductibles are based on the charge determination of Medicare carrier.