DO YOU HAVE SECONDARY INSURANCE INFORMATION YES /NO – IF YES, FILL OUT BELOW
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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.
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I have read, understand and agree to abide by the financial policy of New Image Plastic Surgery.
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New Image Plastic Surger
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 even 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
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Please tell us about your past medical history. Do you have or have you ever had a history of:
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
Female Patients only:
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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.
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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 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 mean 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.
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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.
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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.
Individual Patient’s Authorization
I give my authorization to disclose protected health information to the person/people listed below:
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.
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Bill Of RightsHIPPA PolicyDisclosure Information
