GPS Patient Authorization to Treat(Must Sign Below)
I consent to treatment necessary for the examination, assessment, testing, and medical treatment of the above named patient.
I authorize the release of information related to my examination, assessments, testing and medical treatment to referring and family physicians, and I additionally authorize the same information regarding me for inclusion in the clinical data repositories or electronic health record for ongoing access for the provision of my care.
I agree that, to the extent necessary to determine responsibility for payment and to obtain reimbursement, Graham Plastic Surgery may disclose my information to any person or entity which is or may be responsible for all or a portion of the charges, including but not limited to insurance companies, health care service plans, workers compensation carriers, and medical or utilization review organizations designated by any of the foregoing and any other person or entity as necessary in connection with such payment or reimbursement.
I hereby authorize Graham Plastic Surgery PLLC, its medical staff/employees, to take photographs/digital images/videotapes of myself in whole or in part for establishing a treatment plan, evaluating surgical outcomes, pre-authorization for surgery, educational purposes, and to show prospective patients before and after results from surgery. (when used in this fashion, these photographs/digital images/videotape are not labeled with patient identification and any identifying features (except facial photos) will be edited or removed)