Plastics Intake, Demo & HIPAA

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.
Which office are you being seen in? *
Patient Registration
Patient Name *

First Name M.I. Last Name
Gender *

Male Female
Gender

Male Female
Date of Birth *

Month Day Year
Age *
Social Security #
Street *
City *
State *
Zip *

Phone Number (please enter at least one phone number) *

Phone Number

Cell Phone

Home Phone

Work Phone

Home Phone
Cell Phone
Work Phone
Email Address
Select ONE contact method for appointment reminders *
Opt out of promotional practice emails. (You may also opt out at any time by calling (203) 830-4700.)
Primary Doctor
Primary Doctor Location (City/State)
Was this your referring physician?

Yes No
If no, who was your referring physician?
Information needed for government compliance:
Race *
Ethnicity *
Preferred Language *
Responsible Parent/Guardian

First Name M.I. Last Name
Parent/Guardian Date of Birth

Month Day Year
Parent/Guardian Home Phone
Street
City
State
Zip
Emergency Contact Name *

First Name Middle Name Last Name
Relationship to Patient *
i.e.- mother, father, spouse, etc.
Phone *
Cell Phone
Work Phone
By checking, you authorize Advanced Specialty Care to discuss your medical information with the emergency contact listed above.

I Authorize Advanced Specialty Care to discuss my medical information with the emergency contact listed above.
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.
Is today's visit related to an injury, accident or 3rd party payer? *

Yes No
Primary Insurance Company Information
Information must be filled in completely, even if we copy your insurance card.
Insurance Company Name
Plan
ID #
Group Name/#
Policy Holder's Name
Relationship to Patient
Gender

Male Female
Gender

Male Female
Date of Birth

Month Day Year
Social Security #
Secondary Insurance Company Information
Insurance Company Name
Plan
ID #
Group Name/#
Policy Holder's Name
Relationship to Patient
Gender

Male Female
Gender

Male Female
Date of Birth

Month Day Year
Social Security #

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:
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Patient
Name

First Name Last Name
Phone Number

Area Code Phone Number
Relationship to Patient

I authorize Advanced Specialty Care staff to leave medical information, including test results, on the following voicemail/answering machines: *

Please Check

Phone Number

Home Phone

Cell Phone

Work Phone

I hereby authorize Advanced Specialty Care to correspond with me via email regarding my medical care:

Please Check

Email Address

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.
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.

All Records
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:
Under certain circumstances, this office may need to request lab reports, radiology reports, other diagnostic test results, and/or medication history from outside facilities in order to provide treatment. At times these facilities may require an authorization to release such records. My signature authorizes the release of these records. *
Type Initials
I understand that no procedure provided by this facility is completely without risk and I authorize the care and treatment provided to me under the general or specific directions of my physician or my physician assistant. *
Type Initials
I understand that I will be charged a $25-$125 NO-SHOW fee if I do not show up at my scheduled appointment. In order to avoid the NO-SHOW fee an appointment needs to be cancelled 24 hours prior. *
Type Initials
I understand any office procedures/tests done today may fall under a different insurance benefits classification, therefore may require additional out of pocket cost beyond the office visit fee. *
Type Initials
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.
Patient Signature: *

Parent/Guardian sign if patient is a minor Clear
Relationship to Patient *
Type Full Name *
Date of Acknowledgement *

Month Day Year
Date
Patient's Name if Minor
Patient's date of Birth *

Month Day Year
Date

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

Plastic Surgery Intake Form

Cosmetic Procedures

For Cosmetic Consultations & Appointments