Associates in Plastic & Aesthetic Surgery PATIENT REGISTRATION

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1 PATIENT REGISTRATION Name Date Date of Birth Age Social Security No Demographics Male Female Single Married Divorced Widowed Reason for your Visit Who referred you to this office Doctor Patient Web Site Other Please elaborate (name and phone) If your visit pertains to an injury, what was the date (Information Requested by the Federal Government) Preferred Language English Spanish Other Ethnicity Race Hispanic/Latino Not Hispanic/Latino American Indian/Alaskan Asian African American Native Hawaiian/Pacific Other White PERSONAL INFO Cell # Home # Street City State Zip WORK INFO Occupation Employer Phone # Street City State Zip INSURANCE INFO Insurance (primary) (secondary) Primary Insured Name DOB SS# Relationship to the Insured Emergency Contact Name Phone Relationship Who is your primary medical doctor (name and phone no.)

2 Welcome to the practice FROM OUR PHYSICIANS: Thank you for entrusting your care to us. We are all board-certified plastic surgeons who are licensed to practice medicine in the State of New Jersey. We are committed to providing safe, private and personalized care. PLAY A PART IN YOUR CARE: We encourage all patients to be involved in their care, so feel free to ask questions of anyone in this organization. We do not recognize Do Not Resuscitate (DNR) orders or Living Wills. Please see the office manager with any concerns you may have. INFECTION CONTROL: Our practice educates staff upon hire and annually thereafter in proper infection control techniques and follows CDC guidelines regarding such. We encourage staff to stay home when ill. We provide tissues, garbage cans and hand sanitizers throughout this facility. We request that everyone cover their mouth when coughing or sneezing, and then wash their hands. We value patient safety. SHOULD YOU HAVE A PROBLEM: If you have a concern, you may speak with the office manager, Diane Ballistreri, at The accrediting organization that oversees our compliance with standards of care is the Joint Commission on Accreditation of Healthcare Organizations, and is reachable by calling or ing complaint@jcaho.org. You may contact the office of the Medicare Ombudsman James McCracken at or by visiting OUR FINANCIAL POLICIES: Payment is expected when services are rendered. If the doctor participates with your insurance plan, payment refers to co-payments and deductibles. Otherwise, payment in full is expected. If you require special arrangements regarding payment, please raise this concern prior to services being rendered. If a referral is required, it is your responsibility to obtain one. Otherwise, without such you will be responsible for the full payment. We may submit a claim to your insurance company for non-cosmetic services at our discretion. Submitting an insurance claim after surgery is routinely done as a courtesy and does not relieve you of responsibility for the bill. If your insurance company denies any claim because it is considered medically unnecessary or cosmetic, you will be responsible for full payment. If precertification is required prior to surgery, we will obtain authorization on your behalf. If you provide inaccurate insurance information and such renders the authorization invalid, resulting in non-payment, you will be the responsibility for the entire balance. You will be balanced-billed when insurance payment is received or after 45 days if payment has not been made. The patient should submit any secondary insurance after their primary payment is received. Sixteen percent interest (annually) will accrue on overdue balances not paid within 45 days. If payment of our fees is not made in what we consider to be a timely manner your account may be sent to collection, and may be subjected to additional charges and fees associated with such collection. Regarding non-participation with your insurance plan, your policy is a contract between you and your insurance company. We are not bound by their determination of what is "reasonable and customary." We feel our fees are fair and reflect the high quality of care provided and freely chosen by our patients. If you or a legal representative initiates legal action against a third party due to your injury, you agree to notify us immediately. If it is determined that some other entity is responsible for payment of your bills, and not your health insurance company, something often referred to as a subrogation action, you agree to notify us immediately. In such an instance, any prior arrangement with regard to what we would bill and / or accept as payment will become void if it is determined that contractual obligations would no longer apply given the newly discovered responsible party. In the event of a subrogation action and / or you receive a monetary award as a result of a settlement or other court proceeding pertaining to such event, you agree to have your attorney issue a letter of protection for our full usual and customary fee minus any monies already received, and that such will be paid from the settlement amount prior to any other individual receiving money. Deviation from this may result in added fees and penalties as permissible by New Jersey law. Patient Initials Date:

3 COSMETIC SERVICES: Payment for surgery must be made at least one week prior to the procedure. We reserve the right to impose the following penalties for last minute cancellations: 25% of the full fee if cancellation 48 hours prior, 50% of the full fee if 24 hours prior, and forfeiture of the entire fee for cancellation on the day of surgery. We reserve the right to apply those fees to future surgery in lieu of a refund. We do not submit insurance claims for cosmetic procedures. Payment for a cosmetic procedure covers the surgery on the specified procedural date. Routine postoperative care for 90 days is included in the cost. However, any other treatment or service will incur additional costs unless specifically stated in writing. Such examples include, but are not limited to, garments, scar treatments, surgical revisions or touch-ups, hospital care, treatment of complications, referrals to other specialists, testing, and medications. Your insurance may not cover complications related to cosmetic surgery. It is your responsibility to check with your insurance company if you would like additional information regarding this aspect of care. PHOTOS, VIDEO OR DIGITAL IMAGES: Your signature confirms that you understand that photos, videos or digital images (collectively referred to as "images") may be obtained during treatment and that any or all may be used to document care. By signing, you consent to such "images" being taken and understand that our practice retains all ownership rights to these "images. You will be allowed to view them or obtain copies if you request. These "images" will be secured in a manner consistent with our privacy policy and maintenance of medical records. Any images of you may reveal private or personal details and may further reveal your identity, and your signature acknowledges this as well. See "authorization to release information" regarding release of such "images". PRIVACY PRACTICES / MY RIGHTS ACKNOWLEDGEMENT I have received the Notice of Privacy Practices / My Rights and have been provided an opportunity to review it. HOW WE MAY USE YOUR INFORMATION Our practice collects information and stores this information in a certified HER system. Some of this data is requested / required by the federal government. The questions are part of our encounter forms. When your permission is required for release of such information, you will be asked to sign the necessary release forms. Generally speaking, we are permitted to release your information when it pertains to your treatment, payment, and healthcare operations. We do not sell any personal information. We do collect s and may use your from time to time for the purpose of notifying you about general practice information or new procedures, cosmetic services, and specials. You may choose to unsubscribe if you prefer not to receive s regarding practice information, specials or new procedures. Your will not be used to transmit personal information or HIPAA-protected information unless you specifically give us permission for such use. Our office s are NOT encrypted. You may us with any information you choose, but the transmission of such, and any reply to such, will not be encrypted. Furthermore, do not rely on to transmit any medical information of an urgent or emergency nature. If you have a medical emergency, you should dial 911 or go to the nearest emergency room. If your concern is less than urgent, you may reach us at Patient Initials Date:

4 Associates in Plastic & Aesthetic Surgery AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize "my doctor" or any affiliate to release any and all information regarding my treatment, including digital photos or images, even if they reveal my identity or other private area on my body, to my insurance carrier(s), Workers' Compensation Carrier, Case manager, PIP representative or other health professional as necessary to obtain insurance pre-approval or payment and to process my insurance claim(s) generated in the course of examination and /or treatment. A photocopy of my signature and agreement is to be considered as valid as the original. This order will remain in effect until revoked by me in writing. It is common for patients to request that we speak with a spouse, relative or other person regarding care. Please provide the names below, clearly and legibly. You are giving permission for us to discuss your care with these individuals. Patient Initials Date:

5 Assignment of Benefits & Designation of Authorized Representative I, the undersigned, represent that I have a valid and in-force insurance and / or employee health care benefits coverage, and hereby assign and convey directly to Dr. Charles Loguda, Dr. Howard Tepper, Dr. Jerrold Zeitels, and / or Dr. Richard Tepper (known as "my provider(s)"), their affiliated law firms, or other business associates, collectively referred to as outside business entities (i.e. may be left blank ), as my Statutory Derivative Beneficiary (SDB), commonly known as a Designated Authorized Representative, and a Claimant under the "Patient Protection and Affordable Care Act" (PPACA), existing ERISA, and other applicable federal and state laws, all medical benefits and / or insurance reimbursement, if any, otherwise payable to me for services rendered from "my provider(s)", regardless of the provider's managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize "my provider(s)" to release all medical information necessary to pre-certify a service and / or process my claims under HIPAA, including the release of office records, outside testing or consultation, and digital imagery obtained during the course of treatment. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to "my provider(s)" any and all plan documents, insurance policy and / or settlement information upon written request from "my provider(s)" in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and / or employee health benefits claim submissions. I understand that "my provider(s)" may choose to work with outside business entities on my behalf. Accordingly, all of my rights being assigned herein are also being assigned to these outside business entities. Specifically, I authorize the outside business entities to represent me directly against any insurer for the collection of PIP benefits, Workers' Compensation benefits and all commercial insurance benefits, and confer all of the same rights as above. I give permission for these outside business entities to contact my insurance carrier and engage them as my personal representative for the purpose of securing all possible insurance reimbursements. I hereby convey to "my provider(s)", to the full extent permissible under the law and under any applicable employee group health plan(s), insurance policies or liability claim, any claim, cause of action, or other right I may have to such group health plans, health insurance issuers or tortfeasor insurer(s) under any applicable insurance policies, employee benefits plan(s), or public policies with respect to medical expenses incurred as a result of the medical services I received from "my provider(s)", and to the full extent permissible under the law to claim or lien such medical benefits, settlement, insurance reimbursement and any applicable remedies, including, but not limited to, (1) obtaining information about the claim to the same extent as the assignor, including, but not limited to, issuance of reimbursement checks, Explanation of Benefits and any / all correspondence related to claims reimbursement; (2) submitting evidence; (3) making statements about facts or law; (4) making any request, or giving, or receiving any notice about appeal proceedings; and (5) any administrative and judicial actions by "my provider(s)" to pursue such claim, chose in action or right against any liable party or employee group health plan(s), including, if necessary, to bring suit by "my provider(s)" against any such liable party or employee group health plan in my name with derivative standing but at such provider(s)' expenses. Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA, ERISA, Medicare and applicable federal or state laws. In the event that I receive direct payment of any amounts due for services rendered by "my provider(s)", I agree to forward immediately to "my provider(s)" any checks made payable to me for services rendered, endorsed in the following manner..."pay to the order of "my provider(s)" (entering the actual name of my treating physician in this practice), along with any Explanation of Benefits (EOB) in my possession, and will further keep a photocopy of the check and EOB for my records. Patient / Responsible party acknowledges that he / she has been given ample opportunity to read this agreement, ask questions about it, and is in full agreement with it. A photocopy of this assignment is to be considered as valid as the original. Patient Signature (or authorized person) Print Name Date