arslanian plastic surgery one glenlake parkway suite 950 ... · one glenlake parkway suite 950...

Arslanian Plastic Surgery One Glenlake Parkway Suite 950 Atlanta, GA 30328

PATIENT INFORMATION FORM

PATIENT INFORMATION SHEET REVISED 12/31/16

PATIENT INFORMATION Name First: Middle: Last:

Preferred Name:

Sex: ( ) Male ( )Female Marital Status: S M D W DOB: SSN: Mobile Phone: :

Home Phone:

Work Phone:

Address:

City: State: ZIP Code:

Email address:

Preferred Method of Communication ( ) Email ( ) Home Phone ( ) Mail ( ) Mobile ( ) Work Phone

INSURANCE: ( ) Self Pay ( ) Insurance ( ) Worker’s Compensation - Please complete Part III

PRIMARY INSURANCE INFORMATION Part I Name of Insurance:

Insurance address: Effective Date:

City: State: Zip Code:

Phone: ID# Group #:

Relationship to Insured: ( ) Self ( ) Child ( ) Spouse ( ) Other ( ) Self ( ) Child ( ) Spouse ( ) Other

Copay: $

GUARANTOR INFORMATION Name First: Middle: Last:

Address:

City: State: ZIP Code: Phone:

DOB: SEX: SSN:

SECOND INSURANCE INFORMATION Part II Name of Insurance:


City State: Zip:

Phone: ID# Group#:

Relationship to Insured: ( ) Self ( ) Child ( ) Spouse ( ) Other Copay: $

GUARANTOR INFORMATION: Name Frist: Middle: Last:

Address:

City: State: Zip Code: Phone:

DOB:

EMPLOYMENT: Occupation: Address: Relationship:

Employer’s Name:

Employer’s Address: NEXT OF KIN OR IN CASE OF EMERGENCY: Name First: Middle: Last:

Address:

City: State: ZIP Code: Phone:

Relationship:

Arslanian Plastic Surgery One Glenlake Parkway Suite 950 Atlanta, GA 30328

PATIENT INFORMATION FORM

PATIENT INFORMATION SHEET REVISED 12/31/16

WORKERS’ COMPENSATION Part III Date of Injury: Claim #

Adjustor’s Name:

Current address:


Office #: Fax #:

Email address:

NOTES:

INSURANCE INFORMATION for Workers’ Compensation Name of Insurance:


City: State: Zip Code:

Phone: ID# Group #:

Place of Employment: Name

Address:


Phone:

Assignment of Benefits In consideration of services rendered, I hereby authorize payment directly to ____________., the amount due from my insurance company for services rendered. The provider is a participating provider with a number of insurance companies. I understand that I am financially responsible for any balance not covered by my insurance carrier including deductible and co-insurance. Co-pays are due prior to treatment. This office accepts cash, checks and credit cards. In the event that your insurance company changes to a plan that the provider does not participate in, you may be responsible for all charges whether considered covered or non-covered. I also understand that I will be responsible and I agree to pay attorneys’ fees, which equal 1/3 of the total balance plus any processing fee that might be incurred to collect payment in full. We reserve the right to change the fees without prior notice. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE: __________________________________________ PRINT NAME: ______________________________________________ Date: ______________________

WHOM MAY WE THANK FOR REFERRING YOU TO OUR PRACTICE:

Name:

Address:

Phone:

PatientMedicalHistoryQuestionaire

PatientName________________________________________________________________DateofBirth_____/_____/______ (last) (first) (Middle)

PleaseListanymedicalproblemsthatruninyourfamily

________________________________________________________________________________________________

REVIEWOFSYSTEMS

Fornewpatients,establishedpatientswhomaybehavinganewproblem,orourpatientswhowehaven’tseenfora

while,weneedtoupdateourrecordsastoyourgeneralmedicalhealth.Ineacharea,ifyouarenothavinganydifficulties,

pleasecheck“NoProblems.”Ifyouareexperiencinganyofthesymptomslisted,PLEASECIRCLETHEONESTHATAPPLY,

orexplainanythatmaynotbelisted.Ifyouhaveanyquestionsaboutthis,pleaseaskoneofthetechnicians,oryour

doctor.

Const.(HealthinGeneral)❑NoProblemsLackofenergy,unexplainedweightgainorweightloss,lossofappetite,fever,nightsweats,paininjawswheneating,scalptenderness,priordiagnosisofcancer.

Other:_______________________________________________________________

Ears,Nose,Mouth&Throat❑NoProblemsDifficultywithhearing,sinusproblems,runnynose,post-nasaldrip,ringinginears,mouthsores,looseteeth,earpain,nosebleeds,sorethroat,facialpainornumbness.

Other:_________________________________________________________________

C-V(Heart&BloodVessels)❑NoProblemsIrregularheartbeat,racingheart,chestpains,swellingoffeetorlegs,paininlegswithwalking.Other:_______________________________________

Resp.(Lungs&Breathing)❑NoProblemsShortnessofbreath,nightsweats,prolongedcough,wheezing,sputumproduction,priortuberculosis,pleurisy,oxygenathome,coughingupblood,abnormalchestx-ray.

Other:_______________________________________________________________

GI(Stomach&Intestines)❑NoProblemsHeartburn,constipation,intolerancetocertainfoods,diarrhea,abdominalpain,difficultyswallowing,nausea,vomiting,bloodinstools,unexplainedchangeinbowelhabits,incontinence.

Other:________________________________________________

GU(Kidney&Bladder)❑NoProblemsPainfulurination,frequenturination,urgency,prostateproblems,bladderproblems,impotence.Other:______________________________________

MS(Muscles,Bones,Joints)❑NoProblemsJointpain,achingmuscles,shoulderpain,swellingofjoints,jointdeformities,backpain.Other:___________________________________________

Integ.(Skin,Hair&Breast)❑NoProblemsPersistentrash,itching,newskinlesion,changeinexistingskinlesion,hairlossorincrease,breastchanges.Other:______________________________

Neurologic(Brain&Nerves)❑NoProblemsFrequentheadaches,doublevision,weakness,changeinsensation,problemswithwalkingorbalance,dizziness,tremor,lossofconsciousness,uncontrolledmotions,episodesofvisualloss.

Other:__________________________________________

Psychiatric(Mood&Thinking)❑NoProblemsInsomnia,irritability,depression,anxiety,recurrentbadthoughts,moodswings,hallucinations,compulsions.Other:_______________________

Endocrinologic(Glands)❑NoProblemsIntolerancetoheatorcold,menstrualirregularities,frequenthunger/urination/thirst,changesinsexdrive.Other:_______________________

Hematologic(Blood/Lymph)❑NoProblemsEasybleeding,easybruising,anemia,abnormalbloodtests,leukemia,unexplainedswollenareas.Other:_______________________________________

Allergic/Immunologic❑NoProblemsSeasonalallergies,hayfeversymptoms,itching,frequentinfections,exposuretoHIV.Other:___________________________________________________


PATIENTMEDICATIONFORM REVISED12/31/16

PATIENTMEDICATIONFORM

MEDICATIONALLERGIES:_______________________________________________________________________________MEDICATIONNAME DOSEor

STRENGTHHOWTOUSE/WHEN

TOUSEWHATISTHEMEDICATION

FOR?

APPROXIMATESTARTDATE

Example:Tylenol

650mg

1threetimesaday

Asneededforpain

January2017


Icertifythattheabovelistisaccuratetothebestofmyknowledge_______________________________________________________________________SignatureofPatient/ParentorGuardianifpatientunder18 Date

FINANCIALPOLICYAGREEMENT REVISED12/31/16

OneGlenlakeParkwaySuite950Atlanta,GA30328Phone:678-894-9200Fax:844-894-9205

MedicalPhotographyConsentFormForm

FINANCIALPOLICYAGREEMENTAsyourPhysician,wearecommitted toprovidingyouwith thebestpossiblemedical care. Inorder toachieve thisgoal,weneedyourunderstandingofourpaymentpolicy.FINANCIALAGREEMENT:Wewillgladlydiscussyourproposedtreatmentanddoourbesttoansweranyquestionsrelatingtoyourinsurance.Youmustrealize,howeverthat:1.Yourinsuranceisacontractbetweenyou,youremployer,andyourinsurancecompany.Wearenotpartytothatcontract.Wemustemphasizethatasyourmedicalcareproviders,ourrelationshipandconcern iswithyouandyourhealth,notwithyour insurance company. Some insurance companies require anauthorization to see a specialist. It is your responsibility toobtainthisauthorizationbeforeyouareseeninouroffice.Anychargesdeniedbyyourinsurancecompanyforthisreasonwillbeyourresponsibility.2.Notallplasticsurgeryservicesareacoveredbenefitinallinsurancecontracts.Theinsurancecompanyselectstheservicestheywillcoveroronlycoverinpart.Theymayrequireadditionalco-pays/coinsurances,whichareyourresponsibility.3.Allpatientcosts(deductible,co-pay,coinsurance)quotedtousbyyour insurancecompanyareESTIMATES.Allchargesforservicesrenderedthatarenotacoveredbenefitofyourinsurancepolicyareyourresponsibility.Thefinaldecisionastowhatyouoweisadecisionthat ismadebyyourinsurancecompany,andyouareresponsibleforthatamountregardlessoftheamountchargedattimeofservice.Wewillbillyouforchargesbeyondthoseinitiallyquotedbyinsuranceoranythataredeniedbyinsuranceafterserviceisrendered.Ifthechargesinthefinaldeterminationarelessthanwhatyoupaid,wewillapplyacredittoyouraccount.4.Itisyourresponsibilitytoinformusofchangestoyouraddressand/orphonenumber.Wesendmonthlystatementsofanyoutstandingbalancebymail.Anybalancesthathavenotbeenpaidwithin90days,includingthosethatinsurancehasnotpaid,willbesenttocollections.Invalidaddressinformationwillnotpreventthereferralofoverdueaccountstocollections.Werealizethatemergenciesdoarisethatmayaffecttimelypaymentofyouraccount.Ifsuchextremecasesdooccur,pleasecontactuspromptlyforassistanceinthemanagementofyouraccount.Wewilldoourbesttoworkwithyou.5.Ifthereareanymattersindisputeaftertreatmentorpayment,youwaiveyourrighttoprivacyundertheHealthInsurancePortability and Accountability Act of 1996 (HIPAA) guidelines in order to proceed with the necessary means to collectpayment.Ifyouhaveanyquestionsabouttheaboveinformationoranyuncertaintyregardinginsurancecoverage,pleasedonothesitatetoaskus.Weareheretohelpyou.I understand that insurance is considered a method of compensating the doctor on a patient’s behalf and is not asubstitute forpayment. Iunderstandthat it ismyresponsibilitytounderstandthepoliciesofmy insuranceandtopayanydeductibleamount,co-insuranceorco-payatthetimeofservice.IunderstandthatIamresponsibleforpayinganyclaimsdeniedbymyinsurance.Iagreetopayanyamountnotpaidforbymyinsuranceorthirdpayerwithin90daysofmyexamination.IhavereadandunderstandtheaboveFinancialPolicy._________________________________________________________________ SignatureofPatientorAuthorizedRepresentative Date:____________________________________________________________________________________________________PrintedName

REVISED8/1/17

VIDEO AND PHOTOGRAPH RELEASE / AUTHORIZATION The purpose of this Release/Authorization is to obtain my prior written consent so that Arslanian Plastic Surgery may photograph or film me for one or more purposes for which I do hereby consent.

I hereby consent to and authorize the use and reproduction by Arslanian Plastic Surgery, or anyone authorized by them, of any and all photographs, electronic images or video footage of me taken by APS, or that APS has in its possession, provided either by me or by a third party (collectively, Images) for the purpose of informing the medical profession and the general public about plastic surgery and procedures and techniques without compensation to me. Such use shall include, but not be limited to, distributing the Images via print, visual and electronic media, specifically including the APS website and social media. The Images (including any photographic negatives) shall be the sole property of APS.

I understand that the Images will not be identified by my name. I understand that if I do not want images involving identifiers such as my face, tattoos, or other notable markings, I will state those requests below.

Photo Limitations: ____________________________________________________________________ (For example: No face, no tattoo, etc.)

I hereby release, discharge and agree to hold harmless APS and its affiliates and their respective representatives, assigns, and employees, and any person acting under their permission or authority, from and against any claims whatsoever in connection with the use of my Images and the reproduction thereof as stated above, including any claim for payment in connection with distribution or publication of the video and/or photographs.

I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Arslanian Plastic Surgery.

I understand that once content is posted on the web, it may remain on the web even after the content is deleted from the source.

I hereby warrant that I am at least eighteen years old, and competent to contract in my own name insofar as the above is concerned.

I have read and understand the foregoing release, authorization and agreement, before signing my name below, and enter into it knowingly and voluntarily.

Patient’s Name: _______________________________ Date: __________________

Patient’s Signature: ____________________________

arslanian plastic surgery one glenlake parkway suite 950 ... · one glenlake parkway suite 950...

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