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Home
Meet Dr. Henderson
About Dr. Henderson
Facial Plastic Surgeon vs Plastic Surgeon
Procedures
Ears & Nose
Otoplasty Scottsdale
Rhinoplasty Scottsdale
Eyes And Brows
Brow Lift Surgery Scottsdale
Eyelid Surgery Scottsdale
Face & Neck
Facelift
Facial Implants
Fat Transfer Procedures
Lip Enhancement
Neck and Mid-Face Lift
Non-Surgical Procedures
Laser Resurfacing
BOTOX® Cosmetic
Injectable Treatments
Microneedling
Facial rejuvenation
Renuvion J Plasma
Neck Rejuvenation
Cellenis DermaFiller
Scarlet RF
Agnes RF
AquaFirme XS
Plasmage
Medical Grade Skincare Products
Gallery
Video
Blog
Reviews
Contact
Patient Form
Sitemap
Beautiful
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Patient Form
Patient Form
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New Image Plastic Surgery
Patient name
Account #
Name of physician you are seeing
How did you hear about us?
Internet
Referring physician (Name)
Advertisement
Patient referral (Name)
Primary care physician
Patient address
Street Address
City
State / Province / Region
ZIP / Postal Code
Home phone
Work phone
Cell phone
Email
Date of Birth
DD slash MM slash YYYY
Age
Male
Female
Social security no.
Employer
Occupation
Marital status
M
S
W
D
Who should we contact in case of an emergency? Name
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Telephone
Relationship to patient
Primary Insurance Information
Name of policy holder:
Relationship to patient
Self
Spouse
Child
Other
Date of Birth
MM slash DD slash YYYY
Social security # of the policy holder
Address of Policy Holder
Phone #
Insurance company
Specialty Co-pay amount due
Insurance Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Member ID
Group #
Plan #
DO YOU HAVE SECONDARY INSURANCE INFORMATION YES /NO – IF YES, FILL OUT BELOW
Name of policy holder
Relationship to patient
Self
Spouse
Child
Other
Date of Birth
MM slash DD slash YYYY
Social security # of the policy holder
Employer
Insurance company
Insurance address
Street Address
City
State / Province / Region
ZIP / Postal Code
Member ID
Group #
Plan #
Photo copy both sides of insurance card taken
Yes
No
Release and assignment: I hereby authorize New Image Plastic Surgery to release to any insurance company or their representative(s) any information, including the diagnosis, treatment, prognosis, and charges for any treatment or examination rendered to me for medical or surgical care. I agree that this office may release records pertaining to my treatment to my insurance company or any other third parties responsible for payment of my medical charges, including review activities related to my physician’s participation with my health plan. I also authorize and request your company to pay directly to the above-named physician the amount due in my pending claim for medical or surgical treatment rendered to me. I understand that this does not relieve me of my personal responsibility for all such charges in the event of an insufficient payment or no recovery.
Signature of patient/responsible party
Date
MM slash DD slash YYYY
I have read, understand and agree to abide by the financial policy of New Image Plastic Surgery.
Patient or responsible party signature
Date
DD slash MM slash YYYY
New Image Plastic Surgery
Financial policy
• Insurance
– Your insurance policy is a contract between you and your insurance company. The doctor is not involved in this contract. You are contractually responsible for your co-payment, co-insurance or any balance unpaid at the time of service. We accept cash, check, or Visa/MasterCard. Cosmetic procedures will not be billed to your insurance company. Post-dated checks are not accepted.
• No insurance
– Patients who are self-pay are responsible for the entire balance at the time of service.
• Co-Pays
– All co-pays and past due balances are due at the time of check-in.
• Regarding Insurance
– We may accept assignment of insurance benefits. We will bill your insurance company upon receipt of your current insurance information. If your insurance company has not paid your account in full within 45 days, the balance may automatically be billed to you. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance. Non-covered services and balances due on covered procedures not paid by insurance (i.e.co-pays, deductable, etc.) will be billed to the patient. Additionally, hospital-based services which require a surgical assistant may not be covered by insurance.
• Medicare Medical Necessity
– Medicare will pay only for services that it determines to be “reasonable and necessary” under the Medicare laws. If Medicare determines that a particular service, although it would otherwise be covered, is not reasonable and necessary, Medicare will deny payment for that service. If Medicare denies payment, you are personally and fully responsible for payment.
• FMLA Forms, Disability Forms and Insurance Forms
– Form completion is not a covered benefit under any plan. There will be a charge for completion of all FMLA, Short-term and Long-term Disability forms. Completion of insurance forms is not a covered benefit; there will be a charge for completion of insurance forms.
•Surgery Cancellation
– If your surgery is cancelled two weeks or less prior to the date of the procedure, you will forfeit the $500.00 scheduling fee.
• Children
–The parent seeking medical attention of a child/children is responsible for their co-payment and/or coinsurance at the time of service. The financial arrangement between you and the child/children’s parent does not include our practice.
• Returned checks
– There is a $25.00 fee if your check is returned unpaid. In addition, any future services will require cash or credit card payments.
• Statements
– Charges shown on statements are agreed to be correct and reasonable unless protested in writing within 30 days of the billing date.
• Collections
– Should it be necessary to place your unpaid account with our outside collection agency, you must communicate directly with them.
In the event an account is turned over for collections, the person financially responsible for the account will be responsible for all collection costs including attorney fees and court costs.
• Non-Covered Services
– In the event your service is denied as a “non-covered benefit”, you will be held liable for payment. By signing this document, you understand and accept this responsibility.
Your insurance policy provides coverage for certain benefits and allows for certain “exclusions and limitations,” These exclusions and limitations are outlined in your explanations of coverage (EOC) and summary of benefits documents issued by your insurance carrier.
• Additionally, if you obtain services which are deemed “elective & cosmetic” and submit information to your insurance for reimbursement, we will not reduce our fees to your insurance companies fee schedule or reimburse you for the cost of the procedure. Upon consultation with your Physician, the cost of your cosmetic procedure will be provided.
• NO CHARGE BACK PERMITTED ON ANY CREDIT CARD OR FINANCIAL PLAN.
New image plastic surgery
Patient history
Name
Today’s Date
Date of Birth
MM slash DD slash YYYY
Age
Weight (in kg)
Height(foot/inch)
What are you seeing the physician for today?
Please tell us about your past medical history. Do you have or have you ever had a history of:
Asthma
Yes
No
Diabetes
Yes
No
Gastric Reflux
Yes
No
Tuberculosis
Yes
No
HIV Positive
Yes
No
Colitis Irritable Bowel
Yes
No
Lung Disease
Yes
No
Blood Transfusion
Yes
No
Chemical Dependency
Yes
No
High Blood Pressure
Yes
No
Liver Disease
Yes
No
Urinary Incontinence
Yes
No
Heart Attack
Yes
No
Ulcer Disease
Yes
No
Breast Cancer
Yes
No
Heart Failure
Yes
No
Tendency to Bleed
Yes
No
Depression
Yes
No
Heart Disease
Yes
No
Thyroid Problems
Yes
No
Stroke
Yes
No
Skin Cancer
Yes
No
Transfusion Reaction
Yes
No
Kidney Problems
Yes
No
Reaction to Anesthesia
Yes
No
Hepatitis
Yes
No
Cold Sores
Yes
No
Anemia
Yes
No
Mitral Valve Prolapse
Yes
No
Sleep Apnea
Yes
No
Do You Wear Dentures or have any Loose or Capped Teeth?
Yes
No
Could You Possibly be Pregnant?
Yes
No
Do You Smoke Cigarettes?
Yes
No
Do You Drink Alcoholic Beverages?
Yes
No
Have You Been Treated For any Psychiatric Disorder?
Yes
No
Have You ever Taken Accutaine?
Yes
No
If Yes, When was Your last Dose?
Other Medical Problems or Serious Illnesses not listed above:
Please List All Operations (Including Cosmetic)
Do You Have any Allergic Reactions to Medications?
Yes
No
Do you Have Any Allergies to Latex?
Yes
No
If Yes, What Medication and What is The Reaction?
Please list all of the medications you are currently taking and the dose. Please include over the counter medications, aspirin containing products, herbs and diet drugs such as meridia and metabolife
Medication
Dosage
Frequency
For what illness
Family history (Please check all that apply)
Diabetes
Heart Disease
Stroke
Colon Cancer
Breast Cancer
Ovarian Cancer
Other
If Other
Female patients only:
Total #of pregnancies
Total #of live births
LMP
Patient/Responsible party signature
Date
MM slash DD slash YYYY
Privacy practices acknowledgement
I have received a copy of New Image Plastic Surgery’s notice of privacy practices and have had an opportunity to read it and have any questions answered. I agree to uphold my patient responsibilities as outlined to the best of my ability.
Name
Birthdate
MM slash DD slash YYYY
Signature
Date
MM slash DD slash YYYY
Witness
Date
MM slash DD slash YYYY
Bill of rights
Hippa policy
Disclosure Information
New image plastic surgery
New patient general consent
Please read the following information and then indicate your consent/agreement with those statements by circling yes or no for each statement and then signing the bottom of this page.
1. As required by law, I have received a copy and was informed verbally of the patient bill of rights; and have had an opportunity to receive verbal assistance in understanding and exercising these rights.
Yes
No
2. I consent to allow clinical photographs to be taken of me or the named minor, pre- and post- operatively. I understand that these photographs are for New Image Plastic Surgery's confidential, clinical records and that all photographs remain the property of New Image Plastic Surgery. In the even that New Image Plastic Surgery wishes to use the photographs for medical teaching, included in ethical medical publications for the advancement of medicine and/or use for advertising, i.e. website, brochures, etc., I will be asked to sign a separate consent, specifically outlining the use of the photographs prior to their use.
Yes
No
3. I understand that New Image Plastic Surgery has no financial interest in any supporting medical services (clinical laboratory, X-ray diagnostics, pharmacy, etc.).
Yes
No
4. I understand that I will be informed should my medical case be included in any investigational, research or educational studies.
Yes
No
5. I consent to permit individuals designated by New Image Plastic Surgery’s performance Improvement office to review my patient records as part of New Image Plastic Surgery’s ongoing performance improvement program.
Yes
No
6. I consent to permit a sample of my blood or other bodily fluid(s) to be tested should any person (surgeon, nursing staff or other personnel) at New Image Plastic Surgery be accidently contaminated by either or both substances.
Yes
No
7. I have received a copy/am aware of the practice disclosure (about our practice, including the grievance process) and am comfortable with that information.
Yes
No
Patient/guardian signature
Date
MM slash DD slash YYYY
Witness signature
Date
MM slash DD slash YYYY
New Image Plastic Surgery
Advance Directive Policy
It is the policy of New Image Plastic Surgery not to honor advance directives. This means, if you have any advance directive in effect and you have a procedure in our facility, we will not honor that advance directive. If a problem arises during your procedure, we will do everything within our means to resuscitate you and will call for emergency services via 911. Whether or not you agree with this policy, you are asked to sign and date the appropriate section of this form so that your wishes are honored.
I have read and understand the policy of New Image Plastic Surgery and hereby agree to waive my advance directive rights for this procedure. I further agree that it is my responsibility to notify my family and/or executor of my estate of this decision.
Patient/Guardian signature
Date
MM slash DD slash YYYY
Witness signature
Date
MM slash DD slash YYYY
I have read but do NOT agree with New Image Plastic Surgery’s policy regarding advance directives and therefore will have my procedure scheduled at a different facility.
Patient/Guardian signature
Date
MM slash DD slash YYYY
Witness signature
Date
MM slash DD slash YYYY
Patient Contact Information
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 the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of the individuals home.
Cell telephone
Home telephone
Work telephone
I wish to be contacted in the following manner (check all that apply):
Ok to leave message with detailed information
Ok to leave message with detailed information
Ok to leave message with detailed information
Leave message with call back number only
Leave message with call back number only
Leave message with call back number only
Ok to text to this number
Ok to fax to this number
Ok to fax to this number
Written communication
Email address
Home address
Work address
O.K. to email information
O.K. to mail to home
O.K. to mail to office
Individual Patient’s Authorization
I give my authorization to disclose protected health information to the person/people listed below:
Name
Relationship
Address
Phone number
Others
Consent
I agree to the privacy policy.
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