DeRoberts Plastic Surgery

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Today s Patient Registration Form Mr. Mrs. Miss Ms. Dr. (CIRCLE ONE) DeRoberts Plastic Surgery Last Name First MI Former Name of Birth Preferred Name Social Security No. Marital Status S M W D Sep Sex M F Address Email Address Phone-Home Personal Fax Employer Primary Care Physician Name Pharmacy City/State/Zip Is our office authorized to email? Yes No Phone-Cell Best Contact Method Employer Phone Phone Phone Primary Insurance Information: None Secondary Insurance Information: None Insurance Co. Insurance Co. Identification No. Identification No. Group No. Group No. (If the Policy holder is anyone other than the patient, please complete the next four lines.) Policy Holder s Name Relation to Patient Policy Holder DOB Policy Holder SS No. Referred By:! Social Media! Established Patient, Name:! Mailing! Staff Member, Name:! Internet! Other, Please Specify:! Physician, Name & Contact Number: Responsible Party (If Patient is under 18, this section MUST be completed by parent or legal guardian.) Last Name First MI of Birth Social Security No. Marital Status S M W D Sep Sex M F Address City/State/Zip Phone-Home Phone-Cell Employer Employer Phone Authorization to Release Medical Information & Assignment of Benefits: I authorize DeRoberts Plastic Surgery to furnish my insurance company(s) and/or other physicians involved in my care all information, which may be requested concerning my health. I also assign the claim payments to be made payable directly to DeRoberts Plastic Surgery. Insurance co-payments, deductible, and/or coinsurance portions are due at time of service. I understand that this account is my responsibility and should the account be referred to an attorney or collection agency for collection, the undersigned shall pay reasonable attorney fees and collection expense. Patient/Responsible Party Signature 4900 Broad Road, POB South Suite 2G Syracuse, NY 13215 Phone 315-299-5313 - Fax 315-299-5661

Today s : Medical History DeRoberts Plastic Surgery Name: _ of Birth: _ Age: Sex: M F Marital Status: S M W D Sep Occupation: Specific Reason for Seeing Plastic Surgeon: Habits: Tobacco: Y N Amount: Coffee/Tea/Soda: Y N Amount: Alcohol: Y N Amount: Daily Exercise: Y N Amount: Prescription Medications (include dose) Vitamins/Herbal Regular Aspirin Use: Y N NSAIDs/Ibuprofen (Motrin, Advil): Y N Medication Allergy: Latex Allergy: Tape Allergy Y N Name & Reaction: Y N Source & Reaction: Y N Type & Reaction: Personal Medical History: Abnormal Bleeding: Y N Cold Sores: Y N Hepatitis: Y N Acid Reflux/Heartburn: Y N Diabetes: Y N High Blood Pressure: Y N Anemia: Y N Fainting Spells: Y N Mitral Valve Prolapse: Y N Asthma: Y N Heart Attack/Disease: Y N Seizures: Y N Blood Clots: Y N Heart Surgery/Stents: Y N Skin Cancer: Y N Blood Transfusion: Y N HIV/AIDS: Y N Sleep Apnea: Y N Cancer: Y N Other Not Listed: Please describe all Yes responses: Previous Surgery (date): Pregnancies (normal/c-section; date): Breast Feeding (number/duration): Family Medical History: Abnormal Bleeding: Y N Diabetes: Y N Kidney Disease: Y N Anesthesia Problems: Y N Heart Attack/Disease: Y N Tuberculosis: Y N Cancer: Y N High Blood Pressure: Y N Other Not Listed: Y N Please describe all Yes responses: Primary Care Physician: Referring Physician: Phone: Phone:

DeRoberts Plastic Surgery AUTHORIZATION FOR BEFORE & AFTER PHOTOGRAPHY I hereby authorize Dr. Dean DeRoberts to take my preoperative and postoperative photos for my medical record. I understand that the use of photographs is essential to the planning and evaluation of cosmetic or reconstructive surgery. These photographs are a permanent part of your medical record and will never be shown to anyone else without your consent. Patient s Printed Name Patient or Parent/Guardian Signature AUTHORIZATION FOR USE For various reasons Dr. DeRoberts is often asked to show before and after photographs of patients. I hereby authorize Dr. Dean DeRoberts to use my photos for before and after presentations. All identifying information will be removed if possible to maintain your privacy. Patient s Printed Name Patient or Parent/Guardian Signature

DeRoberts Plastic Surgery AUTHORIZATION OF DISCLOSURES I, (name of patient) give authorization to DeRoberts Plastic Surgery to release information concerning the status of my health care including appointments, test results, and pre/post operative status, with: Name of authorized individual Relationship to patient (i.e. friend or family member) Name of authorized individual Relationship to patient (i.e. friend or family member) ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I have received a copy of DeRoberts Plastic Surgery Privacy Notice. Patient s Printed Name Patient or Parent/Guardian Signature

DeRoberts Plastic Surgery NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our practice is dedicated to protecting your medical information. We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Our practice is required by law to abide by the terms of this Notice. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. Our office is required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. To request a revised notice you may call the office and request that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED: We will use your medical information as part of rendering patient care. For example, your medical information may be used by the doctor or nurse treating you, by the business office to process your payment for the services rendered and in order to support the business activities of the practice, including, but not limited to, use by administrative personnel reviewing the quality of the care you receive, employee review activities, training of medical students, licensing, contacting, or arranging for other business activities. We may also use and/or disclose your information in accordance with federal and state laws for the following purposes: Appointment Reminders We may contact you to provide appointment reminders. Treatment Information We may contact you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. Disclosure to Department of Health and Human Services We may disclose medical information when required by the United States Department of Health and Human Services as part of an investigation of determination of our compliance with relevant laws. Family and Friends Unless you object, we may disclose your medical information to family members, other relatives, or close personal friends when the medical information is directly relevant to that person s involvement with your care. Notification Unless you object, we may use or disclose your medical information to notify a family member, a personal representative, or another person responsible for your care of your location, general condition, or death. Disaster Relief We may disclose your medical information to a public or private entity, such as the American Red Cross, for the purpose of coordinating with that entity to assist in disaster relief efforts. Health Oversight Activities We may use or disclose your medical information for public health activities, including the reporting of disease, injury, vital events, and the conduct of public health surveillance, investigation and/or intervention. We may disclose your medical information to a health oversight agency for oversight activities authorized by law, including audits, investigations, inspections, licensure, or disciplinary actions, administrative and/or legal proceedings. Abuse or Neglect We may disclose your medical information when it concerns abuse, neglect or violence to you in accordance with federal and state law. Legal Proceedings We may disclose your medical information in the course of certain judicial or administrative proceedings. Law Enforcement We may disclose your medical information for law enforcement purposes or other specialized governmental functions. Coroners, Medical Examiners, and Funeral Directors We may disclose your medical information to a coroner, medical examiner, or a funeral director. Organ Donation If you are an organ donor, we may disclose your medical information to an organ donation and procurement organization. Research

We may use or disclose your medical information for certain research purposes if an Institutional Review Board or a privacy board has altered or waived individual authorization, the review is preparatory to research or the research is on only decedent s information. Fund Raising We may contact you to raise funds for our practice. Public Safety We may use or disclose your medical information to prevent or lessen a serious threat to the health or safety of another person or to the public. Worker s Compensation We may disclose your medical information as authorized by laws relating to worker s compensation or similar programs. Business Associates We may disclose your health information to a business associate with whom we contract to provide services on our behalf. To protect your health information, we require our business associates to appropriately safeguard the health information of our patients. AUTHORIZATIONS: We will not use or disclose your medical information for any other purpose without your written authorization. Once given, you may revoke your authorization in writing at any time. To request a Revocation of Authorization form, you may contact: CeCe Stinziano DeRoberts Plastic Surgery 4900 Broad Road, Suite 2G Syracuse, NY 13215 315-299-5313 YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION: You have the following rights with respect to your medical information: You may ask us to restrict certain uses and disclosures of your medical information. We are not required to agree to your request, but if we do, we will honor it. You have the right to receive communications from us in a confidential manner. Generally, you may inspect and copy your medical information. This right is subject to certain specific exceptions, and you may be charged a reasonable fee for any copies of your records. You may ask us to amend your medical information. We may deny your request for certain specific reasons. If we deny your request, we will provide you with a written explanation for the denial and information regarding further rights you may have at that point. You have the right to receive an accounting of the of the disclosures of your medical information made by our practice during the last six years (or following February 1, 2007) except for disclosures for treatment, payment or healthcare operations, disclosures which you authorized and certain other specific disclosure types. You may request a paper copy of this Notice of Privacy Practices for Protected Health Information. You have the right to complain to us and/or to the United States Department of Health and Human Services if you believe that we have violated your privacy rights. If you choose to file a complaint, you will not be retaliated against in any way. To complain to us, please contact: CeCe Stinziano DeRoberts Plastic Surgery 4900 Broad Road, Suite 2G Syracuse, NY 13215 (315) 299-5313 If you would like further information regarding your rights or regarding the uses and disclosures of your medical information, you may contact: US Department of Health and Human Services 200 Independence Ave. SW Washington, DC 20201 THIS NOTICE IS EFFECTIVE AS OF September 1, 2010. REVISION OF NOTICE OF PRIVACY PRACTICES We reserve the right to change the terms of this Notice, making any revision applicable to all the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at our office and will make paper copies of the revised Notice of Privacy Practices available upon request.

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