GLASSMAN PLASTIC SURGERY, PLLC

GLASSMAN PLASTIC SURGERY, PLLC

LAWRENCE S. GLASSMAN, M.D.
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PRIMARY INSURANCE
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SECONDARY INSURANCE
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I authorize payment of medical benefits directly to Glassman Plastic Surgery, PLLC. Attorney fees and costs of collection in the event of default up to 33% additional charge for collection fee. Insurance is not accepted as payment in full.
SIGNED

Clear
DATE
I authorize any holder of medical or any other information about me to release my information to the Social Security Administration and healthcare and financing administrations, its intermediaries, carriers, insurance companies, billing and collection agents of these physicians.
SIGNED

Clear
DATE

YOUR INSURANCE

In the past few years the number of different health insurance programs has increased at an amazing rate. Even within one company, there may be several programs with varying benefit requirements. There is no way that we can possibly know, or keep up to date, with each provision.

Some programs require that a specific facility be used for your x-ray’s, ultrasound or blood tests.

Some programs require pre-authorization, while others do not.

Some insurance companies require PATIENTS to notify them of hospital admits or trips to the emergency

It is YOUR RESPONSIBILITY to know:

1. Whether this office is participating with your particular plan and program.
2. Advise this office of your program’s requirements in advance, each and every time we provide a service. We will do our very best to comply with any reasonable requirements that your program may have.

Please understand that if we have not been advised in advance, of your programs requirement or conditions and we provide a service or use a laboratory that is outside of the program, you will be responsible for appropriate fees.

In addition, there are times that we may not be able to obtain a consultant or laboratory participating with your program. It will be up to you to work this out with your insurance company.

These are not our regulations, they are your insurance company’s regulations and unless you follow them carefully, the insurance company may decline all or part of your claim. Your insurance company should have provided you with a phone number for you to use if you have any questions about your coverage. Please be sure to keep this page with your insurance papers for future references.

I acknowledge receipt of this information.
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DATE
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NEW PATIENT INFORMATION SURVEY
PATIENT

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DATE OF FIRST VISIT

MonthDayYear
Date
REASON FOR VISIT
Cosmetic/Type
Type a question

InternetFriend/RelativePhysician/HospitalTelevisionNewspaper (which paper)RadioYellow Pages
If "Internet", which site?
If "Newspaper", which paper?
Thank You!

PATIENT HIPAA AWARENESS
With my permission, Dr. Glassman may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Dr. Glassman Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. Glassman reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Dr. Glassman may call my home or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With my permission, the office of Dr. Glassman may mail to my home or other designated locations any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and or Confidential.

With my permission, the office of Dr. Glassman may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. | have the right to a request that Dr. Glassman restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this, | am allowing Dr. Glassman to use and disclosure my PHI for TPO. | may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.
SIGNATURE OF PATIENT OR LEGAL GUARDIAN

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DATE
PRINT NAME OF LEGAL GUARDIAN (include relationship to patient)

SMOKING CONSENT
I understand that smoking before and after surgery will adversely affect the healing and circulation and will jeopardize my surgical outcome.
Type a question

I never smokedDo you wear a nicotine patch?I still smokeI have not smoked in over 5 years
I stopped smoking on

GLASSMAN PLASTIC SURGERY, PLLC

NEW PATIENT INFORMATION SURVEY

Thank You!

PATIENT HIPAA AWARENESS

SMOKING CONSENT

HISTORY INTAKE FORM

FAMILY HISTORY

PERSONAL PAST MEDICAL HISTORY