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.

Upload Medication List Photo

If you have a medication list that you would like to attach a photo of instead of writing out all medication, you may upload the file here or take a photo: 

Allergy Disclosures

REVIEW OF NEW SYMPTOMS

Please indicate if you have any of the following symptoms if they are NEW

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 CONSENT
Telemedicine 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. 

Expected Benefits:

• Improved access to medical care by enabling a patient to remain in his/her location while the healthcare provider provides medical information from a distant site 
• Limiting the spread of COVID-19 and other communicable diseases
• Ability to obtain consultation from a distant medical specialist without traveling
• Conservation of personal protective equipment (PPE) such as gloves and masks to reduce shortages for healthcare providers
• Allow medical evaluation and management of patients who are unable to travel 

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:

• Information transmitted may not be sufficient to allow for appropriate medical decision making by the health care provider. For instance, certain parameters of the eye examination cannot be tested remotely, such as eye pressure. In addition, there may be poor resolution of images. This may cause a delay in medical evaluation and treatment.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical errors. 

PATIENT’S ACCEPTANCE OF RISKS
By signing this form, I understand that:

• The laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine will be disclosed to researchers or other entities without my consent.
• I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.
• I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.
• Telemedicine may involve electronic communication of my personal medical information to other medical practitioners located elsewhere, including out of state.
• I understand that no results from the use of telemedicine can be guaranteed or assured.

Consent. By signing below, you consent (agree) that:

• You have read this informed consent form, or someone has read it to you.
• You understand the information in this informed consent form and all of your questions have been answered.
• You have been offered a copy of this informed consent form.

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, and most credit cards. You acknowledge that the amount paid for co-insurances and deductibles are an estimate and the actual amount may vary after the claim has been process. You acknowledge and agree that any payments due to the office will be paid in full and you understand any payments owed to you will be sent via check.

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.

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.

By signing the consent form, I affirm I have read and understand the payment policy and agree to abide by its guidelines.

MEDICARE AUTHORIZATION

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.

ACKNOWLEDGEMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have received an email copy of the Lee Aesthetic Center, LLC, Notice of Privacy Practices effective May 16, 2016.