New Patient Cosmetic Packet 2014

  • Primary insurance : (Copy of insurance card required)
  • Patient History

  • Family History

    Personal medical history (did you ever have?)

  • Other than the services we have already provided for you, What additional services would you like to learn about? Please check all that apply.
  • Aesthetic patient self-assessment

    Facial anatomic representation

    With respect to facial aesthetics, please highlight those areas of the face that bother or trouble you.
    In the boxes provided, please rate these areas on a scale of 1 to 5 (1 being least bothersome, 5 being most bothersome).
    Feel free to draw on the chart to identify any other facial concerns.
  • Office Policy

    All patients must complete our Patient Information sheet before having their appointment and/or procedure.
  • Patient payment obligations

    Welcome to the practice of VIVIAN W.BUCAY, MD, PLLC

    1. Vivian W. Bucay, MD, PLLC requires that payment is due at the time of service. WE DO NOT BILL FOR SERVICES. We accept all major credit cards (and debit cards), checks and cash. If you plan to pay by check, the funds must be in the account and checks cannot be post-dated. You must also be able to provide your driver’s license number.

    2. It is also important to note that health insurance does not pay for cosmetic procedures. We offer Care Credit as a financing option for cosmetic procedures.

    3. I hereby guarantee payment in full to Vivian W. Bucay, MD, PLLC for all charges for services rendered and/or charges exceeding third-party payments (except when prohibited by law or under contract). I also authorize Vivian W. Bucay, MD, PLLC to release all necessary information to government agencies, insurance carriers and others (including independent utilization review organizations) that are financially liable for the services in order to pre-authorize services, determine or challenge medical necessity, and to determine the extent and/or amount of liability. I hereby assign all amounts payable for services rendered to Vivian W. Bucay, MD, PLLC. I understand that this constitutes a waiver of confidentiality that is revocable, unless action has been taken in reliance thereon, and will otherwise remain in force indefinitely in order to effectuate the purposes for which it is given.

    Thank you for reading our Financial Policy. Please feel free to let our billing office know if you have any questions or concerns by calling 210-692-3000.
  • Credit card authorization

    As you know, if you have ever made an appointment/reservation with a salon, hotel or car rental agency, the first thing you are asked for is a credit card to pay your bill. This is an advantage for everyone because it makes checkout easier, faster, and more efficient.

    We are implementing a similar policy. You will be asked for a credit card number at the time you check in and the information will be held in strict confidence. Once we are notified how much you are responsible after your insurance(s) has paid its portion for your treatment, any remaining balance you owe will be charged to your credit card and a copy of the charge will be mailed to your address. Additionally, in the event you are delinquent in timely paying an overdue balance, we reserve the right to charge that amount on your credit card as well. We also request that you provide us with updated credit card information anytime that it is warranted (card expires etc.).

    Handling small balances in this manner is advantageous to you because it will eliminate the necessity to write out (small) check(s). It will also decrease the number of billing statements that we have to generate and mail to you, decreasing our costs.

    This in no way will compromise your ability to dispute a charge or question your insurance company’s payment determination. Co-pays remain due at the time of the visit. If you have a question for us, you may call the office or our billers at 210-521-6555.

    Sincerely,

    Vivian W. Bucay, MD, PLLC
  • To be signed at the appointment time
  • New Patient Consent to the Use and Disclosure of Health Information
    for Treatment, Payment, or Healthcare Operations

  • • A basis for planning my care and treatment,
    • A means of communication among the many health professionals who contribute to my care,
    • A means by which a third-party payer can verify that services billed were actually provided, and
    • A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
  • • A basis for planning my care and treatment,
    • The right to review the notice prior to signing this consent,
    • The right to object to the use of my health information for directory purposes, and
    • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or health care operations