Plastics Intake, Demo & HIPAA

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 NameLast Name
Phone Number

Area CodePhone Number
Relationship to Patient
Name

First NameLast Name
Phone Number

Area CodePhone 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

Email
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:
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 audio and or video-recording staff of ASC (including providers) without explicit permission to do so may result in my being discharged from the practice along with any applicable legal consequences.*
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*

MonthDayYear
Date
Patient's Name if Minor
Patient's date of Birth*

MonthDayYear
Date

	Medication Name and Dosage
1.
2.
3.
4.
5.
6.

	Medication Name and Reaction
1.
2.
3.
4.

	Yes	No
Blood in urine
Leg swelling
Depression
Easy bleeding
Heartburn
Headache
Joint swelling
Rash
Shortness of breath
Visual change
Fever

	Yes	No
High blood pressure
Cancer (If yes, please list type below)
Anemia
Anesthesia reaction
Asthma
Diabetes
Joint swelling
Pregnant or may be
Deep vein thrombosis
Thyroid disease
Seizure disorder
Renal disease
MRSA
Pulmonary embolism

	List any other pertinent medical history:
1.
2.
3.
4.

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

Plastic Surgery Intake Form

Cosmetic Procedures

For Cosmetic Consultations & Appointments

	Yes	No
Diabetes
Blood disorder
Anesthesia reaction
Thyroid disorder
Coronary artery disease
Cancer (If yes, please list type below)

	Yes	No
Appendectomy
Gallbladder
Hernia Repair
Hand Surgery

	List any other surgeries not included above:
1.
2.
3.
4.