• Advanced Specialty Care Plastic Surgery: Patient Registration, Intake & HIPAA

    If the patient is a child, fill out the form as it pertains to the child.
    Advanced Specialty Care Plastic Surgery: Patient Registration, Intake & HIPAA
  • Patient Registration

  •  / /Pick a Date


  • Information needed for government compliance:

  •  / /Pick a Date
  • If your insurance plan requires an insurance authorization referral to this office, you must have this referral at the time of your visit, or full payment will be expected.

    It is your responsiblity to ensure your authorization referral is current and on file with this office prior to seeing the physciian for all visits, including follow-ups. There are NO exceptions to the office referral policy.

    *HSA POLICY- If you have a health savings account insurance plan, and your deductible has not been met, we request payment at the time of service. For self-pay patients and those with HSA policies, payment is expected at time of service and a payment plan can be discussed with our billing department if needed **Your office visit can range anywhere from $150-$375, to additional testing randing from $200-$1200.

  • Primary Insurance Company Information
    Information must be filled in completely, even if we copy your insurance card.
  •  / /Pick a Date
  • Secondary Insurance Company Information
  •  / /Pick a Date
  • Acknowledgement Of Receipt and Acceptance Of:

    Notice of Privacy Practices
    Informed Consent
    Practice Financial Policies

    Medical Records Fax: 203-730-4166
    107 Newtown Rd, Danbury CT 06810
    Privacy Officer: Jennifer Retter (203) 830-4700 ext. 8265

    As required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Connecticut law, this practice may not use or disclose your individually identifiable health information without your authorization except as provided in our Notice of Privacy Practices.  Your completion of this form means that you are giving permission for the uses and disclosure described below.  It may be invalid if not fully completed.  Please note record requests are now processed through the patient portal at no charge. If you need paper copies of your records printed there is a 0.65 cent per page fee, per section 20-7c of the Connecticut statute.

  • I hereby acknowledge that I was given the opportunity to review this medical practice’s Notice Of Privacy Practices (HIPAA), and that I have the right to ask for a paper copy of the Notice to take with me.

    I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.

    Due to HIPAA laws, we are unable to share your medical information with anyone unless you authorize to do so. I authorize the person(s) listed below to discuss my medical information:

  •  -
  •  -
  •  
  •  
  • Release of my medical records to my personal electronic portal authorization. I understand that this health information may include HIV-related information and/or information relating to diagnosis or treatment of psychiatric disabilities and/or substance abuse and that by signing this form, I am authorizing such information to be disclosed.

  • Please note that ASC employees may discuss payment issues with family members or other personal representatives, including the subscriber of my insurance plan, unless I request special privacy protections. My signature on this form authorizes such financial discussion.

    Please initial each statement on line provided:

  • If this office does not have a contract with my insurance company, payment must be made at the time of visit unless prior arrangements have been made with the office manager. For patients with coverage that we participate with we will file your insurance claims to your primary carrier for all services and procedures we provide. It is your responsibility to secure all referrals and authorizations required by your health plan and to be aware of its coverage and benefits. All charges are your responsibility from the date the services are rendered. I understand that, regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. If payment is not received in a timely manner, my account will be turned over to a collection agency. I agree to notify the office of Advanced Specialty Care of any changes to my insurance coverage so that filing my claim is expedited. I understand that any unpaid balances 120 days or older will incur $15 per month late fee.

  • Clear
  •  / /
    Pick a Date
  •  / /
    Pick a Date
  • Plastic Surgery Intake Form

  •  - -
    Pick a Date
  •  -
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  • Social History:
    (Smoking status for patients 13 years and older)

  • Cosmetic Procedures

  • For Cosmetic Consultations & Appointments

  • Should be Empty: