Medical History Patient Information : Name DOB Age Ht: ft. in Wt: lbs. Gender: Marital Status Procedure(s) you are considering:

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1 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Dr. Marisa Lawrence to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO), (Marisa Lawrence, M.D., F.A.C.S. Notice of Privacy Practices provides 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. Marisa Lawrence, M.D., F.A.C.S. reserve the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: Marisa Lawrence, M.D., F.A.C.S. 980 Johnson Ferry Rd. Suite 110 Atlanta, GA With this consent, Marisa Lawrence, M.D., F.A.C.S. may call, , or mail to my home or other alternative location and leave a message on a voic or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. I also give permission to receive marketing s from the office of Dr. Marisa Lawrence. I understand that my will not be sold to a third party. Opt Out Marisa Lawrence, M.D., F.A.C.S. 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 form, I am consenting to Marisa Lawrence, M.D., F.A.C.S. s. use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Marisa Lawrence, M.D., FACS may decline to provide treatment to me. I understand I have the right to blog, rate or otherwise publish comments about my procedure and/or my doctor. In the event, I publish negative comments, I hereby waive any medical privacy rights I may have at the time for the limited purpose of giving my doctor permission to respond in the same forum in a factually- -accurate and non- -defamatory manner. I give my permission to discuss my medical care and condition with the following individuals (please list name and number)

2 Medical History Patient Information : Name DOB Age Ht: ft. in Wt: lbs. Gender: Marital Status Procedure(s) you are considering: Personal Physician: Specialists: Date of last physical: Date AND location of last Mammogram: Date & location of last eye exam: Do You Have or Had? Fill out every box. Explain in Margins Symptoms Y N Symptoms Y N EYES RESPIRATORY Loss of Vision Asthma Visual Disturbance Bronchitis Emphysema ENDOCRINE Elevated Cholesterol CARDIO/VASCULAR Thyroid/ Glands Chest Pain Diabetes/Pre-diabetic High Blood Pressure Vascular Disease EARS/NOSE/MOUTH/THROAT Heart Attack Allergies Irregular Heart Beat Sinus Congestion Stroke Chronic Cough GASTROINTESTINAL CONSTITUTIONAL Diarrhea Fever Constipation Use of Diet aids, laxative Stomach Ulcer SKIN Reflux Disease (GERD) Cancer GENITOURINARY NEUROLOGICAL Genitals/Kidney/Bladder Headaches Prostate Seizures LYMPHATIC/HEMATOLOGICAL BREAST Anemia Abnormal mammogram Bleeding Problems Surgery/Biopsy i.e. blood clot Breast fed BONES/MUSCLES Arthritis CANCER Type AUTOIMMUNE Treatment AIDS/HIV + PSYCHIATRIC Depression CORTISONE/STEROID THERAPY

3 Does any blood relative have or had any medical problems? (List relative and disorder) Current Medications ( dosages, OTC meds, alternative therapies) **Please include any vitamins, supplements, such as ibuprofen, aspirin, or herbal products. Allergic to any medications? Allergic to latex or tape? Habits/ Risk Factors: If none, put none. Do not leave any blanks. Nicotine: Type: Years: Quit: Alcohol: Amount: Frequency: Quit: Drugs: Type Frequency: Quit: Any history of substance abuse? Caffeine: Type Frequency Quit: Exercise: Special Dietary restrictions: Travel: Exposure to sun/tanning beds: Reproductive History: Pregnancies: Births: Breast Fed: Y N Times? How long? Last Menstrual Cycle: Menopause (age) List all Surgical procedures: (include office procedures; put in chronological order) List all Hospitalizations: Have you or any family members had any difficulties with Anesthesia? If Yes; please explain: Is there anything else you think the doctor should know about your medical history? Would you accept a blood transfusion if necessary? Referred by: Signature: Date:

4 Patient Financial Policy Thank you for choosing this office as your plastic surgery providers. Your clear understanding of our financial policy is important to our professional relationship. Our prices represent reasonable charges for the Metro-Atlanta area. Please read this document and sign below. Your signature below acknowledges the fact that you have read, understand, and accept your financial responsibility with our office. Reconstructive Surgery Reconstructive consultations, pre-operative evaluations, procedures, and non-global post-operative fees will be billed to your insurance company. Dr. Lawrence is under contract with most insurance companies and accepts out-of-network benefits for all others. It is your responsibility to understand your insurance policy and to provide our office with your current active insurance information. If we do not have this information at the time of your visit, you will be responsible for all fees. If your plan requires us to have a referral from a primary care physician for your visit, this must be received 48 hours prior to your appointment. Your appointment will be rescheduled if we do not have your referral. All copayments, deductibles and co-insurance payments are due at the time of service. Your initial consultation fee includes verification of insurance benefits, photographs (if required), and precertification of proposed procedures. The initial consultation fee is subject to the copayments and deductible as determined be your insurance company. In some cases, the entire consult fee may become your responsibility if your deductible has not been met. By contractual agreement with your insurance company, we are unable to waive these fees. We will file your insurance claims on your behalf for Dr. Lawrence's fees. Your insurance company may require additional information from you directly as the insured. It is your responsibility to comply with their request. We will not become involved in disputes between you and your insurance company. Reconstructive procedures require precertification by your insurance carrier. Our office will request preliminary approval for your procedures following your consultation. The process may take up to 6 weeks. Surgery will not be scheduled until the authorization from your insurance company is received. If your insurance company s policy is to review claims for payment after a procedure is performed rather than issue a pre-certification, a $ deposit, in addition to co-payment, deductible, and co-insurance fees, will be collected. This deposit will be refunded once all fees have been paid. An insurance authorization is not always a guarantee of payment. If your insurance company denies payment of your procedure post-operatively, you will be responsible for the fees in full. Dr. Lawrence utilizes a certified surgical assistant (CSA) in the operating room to assure the highest quality of care. This CSA is provided by NSH and will be billed to your insurance company by the CSA. Any applicable co-pay, deductible, or co-insurnaces will apply. If you choose to schedule surgery without authorization from your insurance company, you will be considered a self-pay patient in the practice. Under these circumstances we will not file an insurance claim, speak with your insurance company, nor accept any insurance payment for your procedure at any time. The balance on your account is ultimately your responsibility. Outstanding balances greater than 90 days must be paid in full or they will be referred to an outside collection agency. You will be responsible for all collection costs. Once an account is referred to collections we cannot withdraw it or accept payment in our office.

5 Self-Pay Surgery The consultation fee is $100 and due at the time of service. This fee will be credited towards your surgery or any procedure with this office if the procedure is scheduled within one year of the consultation date. A self-pay surgery quote includes the surgeon s fee, facility fee, and anesthesia fee. The surgeon s fee is payable to Dr. Lawrence. Facility and anesthesia fees are payable to either Northside Hospital or Perimeter Surgery Center. The quoted fees are based upon an estimate of the average length of time it has taken Dr. Lawrence to perform similar procedures in the past. If surgery extends beyond the time quoted, you will be billed by the facility and anesthesiologist for additional fees. Likewise, you will receive a refund from the facility and anesthesiologist if your surgery is completed in a shorter period of time. The surgeon s fee on the cosmetic surgery quote is valid for 6 months from the date quoted unless a special is noted. Facility and anesthesia fees may change; you will be notified of the current prices at the time of surgery scheduling. You are responsible for x-ray, laboratory, pathology, and medication fees as necessary. A non-refundable and non-transferable scheduling fee of $ must be made at the time a surgery or office procedure is scheduled. In the event your procedure is rescheduled for any reason, this fee may be applied to the procedure if rescheduled within 6 months from the original surgery date; otherwise it will be forfeited. Payment for the balance of the surgery fee is due 14 days before surgery. If fees are not provided by this time the surgery will be cancelled. Procedures cancelled within 14 days of surgery will incur a 50% penalty fee per procedure scheduled. No refunds will be issued on procedures that are cancelled within 48 hours of surgery. Revisions are occasionally necessary with all plastic surgery procedures. Revision procedures in the office will incur a $ supply fee. All other revisions will be billed on a case to case basis. We do not have in-office payment plans, but refer patients to Care Credit at We participate in the 6 months deferred financing option with a minimum $200 purchase. Combination Reconstructive/Self-Pay Surgery You are responsible for your insurance co-payment and your self-pay consultation fee at your initial visit. Precertification for the insurance portion of your surgery will be submitted by this office. Your charges will be split into insurance and self-pay fees by the office, facility and anesthesiologist. You will be responsible for your copayments, deductible, and coinsurance payments as well as your self-pay fees. From time to time as an executive decision, billing and costs may be waived to aid in the care and treatment of patients. Nothing in this decision or act shall be construed as an admission of negligence or substandard care but only an assistance to facilitate patient care. I have read and understand all three pages of the above Patient Financial Policy for Dr. Marisa Lawrence s office Office Policies

6 Accepted payment methods are cash, American Express, Discover, MasterCard and Visa. We do not accept personal checks. Patients who fail to show for a scheduled appointment or cancel within 24 hours of their scheduled appointment will be charged a $25.00 late cancellation fee. Patients with three or more cancellations will be required to provide a credit card payment of $ to hold their appointment. The $ will be refunded upon arrival to the office for the appointment. Refunds are not issued on products or unused portions of services purchased. Services that are performed that are paid with a credit card or a financial third party are not eligible for payment challenges after services are performed. I allow Dr. Marisa Lawrence to use and disclose my protected health information to any Credit Card Entity or Financing Company when they request such information to process an account and assist with payment. All surgeries that are rescheduled for any reason will be charges a $ administration fee. This is not covered by insurance. Copies of medical records will be provided within 30 days upon receipt of a written request, in accordance with Georgia State Law. Patient will incur a $25.88 retrieval fee per transaction, which must be paid before the records are processed. Additionally, fees will be charged for page reproduction according to Georgia State Law. Additional fees will be applied for paper copies of photographs. An itemized invoice will be provided. There is a $40.00 fee for completion of all disability paperwork per transaction. Please do not bring children to appointments unless they are receiving care by the physician. Children cannot sit in our waiting room unattended and may not be in the room when procedures are being performed or medical equipment is in use. I have read and understand the above Office Policy for Dr. Marisa Lawrence s office.

7 Address: City: State: Zip: Home Phone #: Work Phone #: Cell Phone #: Pharmacy #: Address: Date of Birth: Social Security #: Employer/School: Occupation: Insurance Information (Please present your insurance card for us to copy) Name of Primary Insurance Holder: Primary Insured s Social Security #: Primary Insured s Date of Birth: Name of Insurance Company: Policy #: Group #: I accept responsibility as Guarantor for the above named patient. I authorize release of any medical information necessary to process claims for services rendered. I assign, transfer and set over to Marisa Lawrence, M.D., F.A.C.S all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize payment of these benefits to Marisa Lawrence, M.D., F.A.C.S.. I accept responsibility for any balances unpaid by my insurance company. Signature (Patient or Authorized Person) Date Witness 980 Johnson Ferry Road NE, Suite 110, Atlanta, GA P: F:

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