New Patient Cosmetic Packet 2014 Preferred Location:*La Casita - 326 W. Craig PlaceSonterra - 18707 Hardy Oak BoulevardPatient Name: First Last Driver license number: (REQUIRED- Of responsible party in case of minor)Home address :* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code APT#Work place phone # :Home Telephone #:Cell phone #:Email address : Social security # :*Your birthday : Marital Status:SingleMarriedPartneredDivorced/SeparatedWidowedSex:MaleFemaleOccupation :Employer's name :How did you hear about us?Please SelectInternetSearch EngineFacebookTwitterYellow PagesNewspaperPostcard / FlyerReferralReferred by :Your Physician :Telephone number :Your Pharmacy :Telephone number :Preferred Pharmacy :Emergency Contact :Telephone number :Primary insurance : (Copy of insurance card required)Insurance Company :*Please SelectPrivate payMediBlue Cross Blue ShieldCignaHumanaUnited Health CareAetnaID #*Group:Policy Holder’s Name :Birth date of Subscriber : Policy Holder’s Soc. Sec. #:Relation to patient :SELFSPOUSEDEPENDENT*I authorize the release my records to any referring physician or appropriate insurance company and medical information acquired in the course of my examination or treatment.*I agree to pay a cancellation fee of $50 for a medical appointment and $100 for a cosmetic appointment if I do not keep my appointment or if I cancel with less than 24 hours notice.Reason for your visit today :Patient HistoryMedications (including RX, Birth Control Pills, Aspirin, Supplements and other OTC medications) :Drug Allergies :Do you have adverse reactions to dental anesthesia?YesNoIf yes, what reaction?Family History Personal medical history (did you ever have?) Skin CancerMelanomaUnusual MolesAsthmaYesNoLiver DiseaseYesNoHIV +/AIDSYesNoHepatitisYesNoKidney DiseaseYesNoRisk Factors for HIVYesNoPacemakerYesNoCancerYesNoMitral Valve ProlapseYesNoDiabetesYesNoKeloidsYesNoCardiac DiseaseYesNoUlcersYesNoBleed EasilyYesNoGastrointestinal DiseaseYesNoHypertensionYesNoSkin CancerYesNoArthritisYesNoGlaucomaYesNoMelanomaYesNoPsychiatric HistoryYesNoTuberculosisYesNoOther than the services we have already provided for you, What additional services would you like to learn about? Please check all that apply. Skin care regimen Scars(acne or surgical) Dark circles/puffiness Fraxel Re:Pair Acne Rash Facial veins Fraxel Re:Store Uneven skin tone Facial contouring Hand rejuvenation Liquid Facelift Blotchy Skin Neck wrinkles Botox/Dysport/Xeomin Pelleve Skin discoloration Lines around mouth and nose Restylane/Perlane Chemical Peels Rough skin texture Frown lines between brows Juvederm/Juvederm Ultra Laser Hair Removal Rosacea/Facial redness Sagging skin Radiesse Smooth Shapes Brown spots or freckles Thin lips Sculptra Gemini Laser/Facial Rejuvenation Age spots Drooping eyelids/brows Boletero Lipodissolve Red spots Nose shape or size Ultherapy Other not listed 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.Forehead12345Frown lines12345Freckles and pigmentation12345Crow’s feet12345Blood vessels12345Dark circles12345Scarring12345Nasolabial folds (Nose-to-mouth lines)12345Vertical lip lines (smokers’ lines)12345Oral commisures (Corner-of-themouth lines)12345Lips: Definition and/or Fullness12345Larger pores, poor skin texture, & fine lines12345Marionette lines (Mouth-to-chin lines)12345Office Policy All patients must complete our Patient Information sheet before having their appointment and/or procedure.Regarding medication refills:* It is your responsibility to ask your provider for any prescription refills needed at the time of your appointment. If you need medication refills between appointments, contact your pharmacy to see if there are refills remaining on your prescription. If no refills remain, have the pharmacy fax the request to our office at 210-692-3056 (fax). Many medications are not covered by insurance companies - ask your insurance provider for a list of medications not covered under your plan. Confirming / Cancelling Appointments:* You will receive a text and/or email reminder regarding appointments. Please confirm or cancel your appointment by responding to this email/text or calling our office at (210) 692-3000. Regarding insurance with whom we participate:* You are responsible to supply our staff with your ID cards. We will automatically file the claim for you if we accept your health insurance plan, however, you are responsible for any deductible or co-pay due at the time of service. If any of the procedures performed here are not a covered item under your plan, you be financially responsible for payment in full. Regarding insurance with whom we do not participate:* It is your responsibility to understand with which insurance plans Vivian W. Bucay, MD, PLLC participates. If we do not accept your health insurance, the bill is your responsibility and payment in full is due at the time of service. Your health insurance policy is a contract between you and your insurance company, and it is your sole responsibility to understand its terms and conditions, this includes all prescribed medications. Because Vivian W. Bucay, MD, PLLC does not participate with your health insurance company, we do not have a contract with your insurer. We are happy to give you a copy of your bill so you can file directly with your health insurance company. Understand that the ultimate responsibility for payment remains yours. Regarding Medicare and supplementary insurance:* We will automatically file your claim directly with Medicare and any other supplementary secondary insurance, if applicable. However, you remain responsible for your yearly deductible as well as any remaining co-payment. Regarding laboratories:* It is your responsibility to understand with which laboratory your insurance company affiliates. We are not liable for any services rendered to you by a laboratory that does not participate with your health insurance company. Payments:* We accept cash, check, money order, Visa, American Express, Master Card, Care Credit and Discover. There is a $50.00 fee for any returned check. WE DO NOT BILL. If this account is referred to a collection agency for nonpayment, there will be an additional 30% fee added to the outstanding balance. * Please be advised Humana Access Medical cards are not permitted to purchase products. Please be aware that products should never be charged on any HSA (Health Savings Account) cards as products, do not qualify as medical expenses per the HSA guidelines set forth by the US Government, even those sold by a physician * I certify that I have read this form and fully understand its contents. I also acknowledge that no guarantees have been made to me as to the results of examinations of treatment. 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.* Accepted and Agreed: 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* I accept and agree that Vivian W. Bucay, MD, PLLC can charge outstanding balances on my account for medical services of less than $100.00 to the credit card below. In case of amounts exceeding $100.00, we will call you and notify you of the balance. I acknowledge that I have had an opportunity to ask questions about this process. Credit card type : Amex Mastercard Visa Other : Other Card :Account number:*Month:*00010203040506070809101112/ Year :*CVC :*Name on card :*To be signed at the appointment timeNew Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations* I understand that as part of my health care, Vivian W. Bucay, MD, PLLC originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: • 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* I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: • 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* I understand that Vivian W. Bucay, MD, PLLC is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations. * I further understand that Vivian W. Bucay, MD, PLLC reserves the right to change their notice and practices and prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Vivian W. Bucay, MD, PLLC change their notice, they will send a copy of any revised notice to the address I’ve provided (whether U.S. mail or, if I agree, email). I wish to have the following restrictions to the use or disclosure of my health information:* I understand that as part of this organization’s treatment, payment, or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax. e-Signature :*Date This iframe contains the logic required to handle AJAX powered Gravity Forms.
