New Patient Paperwork

Thank you for choosing us as your health care provider. We are committed to providing you with the best medical care service.  The following information is intended to prevent uncertainties in regards to our financial policy. Our practice firmly believes that a good doctor-patient relationship is based upon understanding and strong communication.

Insurance: Dr. Kimberly Lee, M.D. is an out of network provider for all major insurance companies. As a courtesy, our practice will review your insurance coverage, estimate your insurance company payment, review your insurance form, and file your claim with your insurance carrier. You will be responsible for any portion of your bill which is denied or not paid by your insurance carrier. Your insurance coverage is a contract between you and your insurance carrier. If an insurance problem occurs, you will be asked to assist us in contacting your insurance carrier. We feel it is necessary to work together to resolve any insurance problem. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

Deductible: Your deductible will be verified at the time of service and if you have not met your deductible you are required to pay at the time of service. All Medicare patients have a yearly deductible. Payment for services will qualify towards the yearly deductible beginning January 1 and conclude on December 31 of each year. For example, if your yearly deductible is $200, you must first pay the initial $200 to satisfy your deductible. The discount you receive from your insurance company will be calculated when we receive the explanation of benefits for your service and any adjustments will be made at the time.

Co-Payment: All co-payments must be paid at time of service.

Method of Payment: Please let us know what method of payment you will be using: CASH OR CREDIT CARD. NO REFUNDS.

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS: I hearby authorize Kimberly Lee M.D to furnish information to insurance carriers or financial institutions for billing purposes concerning illness and the treatments I receive, and I hereby irrevocably assign to the doctors all payments for medial services rendered. I understand that I am financially responsible for all charges not covered by my insurance benefits. I also authorize that photographic copy of this authorization is as if such copy were original. I also authorize the doctor to file a formal written complaint with the insurance commissioner if my insurance fails to pay or deny a claim within 30 days. I have read, understood, and agree to the provisions of this form.

1. Cancellation/ No Show Policy for Doctor Appointments
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family.  However, when you do not call to cancel an appointment, you are preventing another patient from being able to see Dr. Lee at that time.  Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to seemingly "full" appointment book. If an appointment is not cancelled at least 48 hours in advance you will be charged a fifty dollar ($50.00) fee; this will not be covered by your insurance. 

2. Scheduled Appointments/ Late Policy

We understand that delays can happen, however, we must try to keep the other patients on time for Dr. Lee. If a patient is 15 minutes past their scheduled time we may have to reschedule the appointment.

3. Multiple Missed, Late, or Rescheduled Appointments Policy
Habitually missing or changing appointments is grounds for dismissal from the practice. This applies to surgeon appointments, consultations, skin care appointments, etc.

As a courtesy, we attempt to remind our patients by phone of their scheduled appointments. However, it is the patient's responsibility to keep his/her appointments whether or not a reminder call is received.

I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guarantee the payment of all amounts when it is due. A copy of this agreement shall be considered effective and valid as original.

DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS.
MY SIGNATURE BELOW INDICATES I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS STATED IN THIS FINANCIAL AGREEMENT/ CANCELLATION POLICY.

I understand and accept that I may be recognized from my likeness or case history. Nevertheless, I authorize my surgeon to use my photographs, videotapes and case information in educational and scientfic settings including lectures and multi-media presentations for an audience of medical professionals, at which members of the press may be present, and medical, surgical and scientific journal articles.

Neither I, nor any member of my family, will be identified by name in any publication. I understand that in some circumstances the photographs may portay features, which shall make my identity recognizable.

I authorize the use of my photographs, videotapes and case information in the following commercial/educational settings: my surgeon's office patient education materials; my surgeon's file of pre- and post-operative patient photographs available to prospective patients for viewing in the office; newspaper and magazine articles in which my surgeon participates; televsion programs in which my surgeon participates; my surgeons's personal web site or web page; and lectures and multi-media presentations given by my surgeon for the general public.

I release and discharge Dr. Kimberly Lee, M.D. and all parties acting under their license and authority from all rights that I may have in the photographs and from any claim that I may have relating to such use in publication, including any claim for payment in connection with distribution or publication of the photographs.

I grant this consent as a voluntary contribution in the interest of public education and certify that I have read the above authorization and release and fully understand its terms. 

I understand that I am entering into a contractual relationship with Physician Dr. Kimberly Lee for professional care. I further understand that meritless and frivolous claims for medical malpractice have an adverse effect upon the cost and availablity of medical care, and may result in irreparable harm to my medical provider. As additional consideration for professional care provided to me by Physician, I, the patient/guardian and/or my representative agree not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical malpractice against Physician Dr. Kimberly Lee.

Futhermore, should a meritorious medical malpractice case or cause of action be inititated or pursued, I (the patient) and/or representative agree to use American Board Specialties ("ABMS") board-certified expert medical witness(es) in the same specialty as Physician. Futhermore, I agree that these expert witnesses will adhere to the guidelines and/or code of conduct defined for expert witnesses by the:

American Academy of Facial Plastic Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck and American Medical Association.

In further consideration for this, Physician agrees to the same stipulations.

 

Kimberly J. Lee, M.D., Kimberly J. Lee MD Inc, Beverly Hills Facial Plastic Surgery Center (collectively labeled "Physician") agree to provide treatment to undersigned patient ("Patient"). The physician takes pride in being able to extend a greater degree of privacy than is required by law.

Federal and State privacy laws are complex. Unfortunately, some medical offices try to find loopholes around these laws. For example, physicians are forbidden by law from receiving money for selling lists of patients or medical information to companies to market their products or services directly to patients without authorization. Some medical practices, though, can lawfully circumvent this limitation by having a third party perform the marketing. While personal data is never teqhnically in the possession of the company selling its products or services, the patient can still be targeted with unwanted marketing information. Physician believes this is improper and may not be in the patient's best interest. Accordingly, Physician agrees not to provide medical information for the purpose of marketing directly to Patient. Regardless of legal privacy loopholes, Physician will sever attempt to leverage its relationship with Patient by seeking Patient's consent for marketing products for others.

We want your feedback. If our office gets it right, please tell us. If we could improve on something, please tell us. We take quality improvement seriously. Calls to and from the office may be recorded for quality insurance. While there are scores of "rating sites" in cyberspace, many fail to provide useful information. Let's get it done right. We can make recommendations as to which sites follow minimum standards for fairness and balance. Just ask us.

Physician has invested significant financial and marketing resources in developing the practice. Nothing in this Agreement prevents a patient from posting commentary about the Physician - practice, expertise, and/or treatment - on web pages, blogs, and/or mass correspondence. In consideration for treatment and the above noted patient protection, if Patient prepares such commentary for publication on web pages, blog and/or mass correspondence about Physician, the Patient exclusively assigns all
Intellectual Property rights, including copyrights to Physician for any written, pictorial, and/or electronic commentary. This assignment shall be operative and effective at the time of creation (prior to publication) of the commentary.

As a matter of office policy, Physician is requiring all patients in its practice sign the Mutual Agreement so as to establish that any anonymous or pseudonymous publishing or airing of commentary will be covered by this agreement for all Physician's patients.

Patient and Physician acknowledge that breach of this Agreement may result in serious, irreparable harm. Patient and Physician agree to the right of equitable relief (including but not limited to injunctive relief). Should a breach of this Agreement result in litigation, the prevailing party in the litigation shall be entitled to reasonable costs, expenses, and attorney fees associated with the litigation. Patient has been given the opportunity to ask questions and receive satisfactory and adequate explanations.

To Our Patients:

This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your health information.  This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our Commitment to Your Privacy:

Our practice is dedicated to mainting the privacy of your health information. We are required by law to maintain the confidentiality of your health infomration.  We realize that these laws are complicated, but we must provide you with the following important information:

Use and Disclosure of Your Health Infomration in Certain Special Circumstances:

The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies that are authorized by law to collect information. 

2. Lawsuits and similar proceedings in response to a court or administrative order.

3. If requried to do so by law enforcement official.

4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.  We will only make disclosures to a person or organization able to help prevent the threat. 

5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact our front desk receptionist.

6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complain with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Kimberly Lee, M.D.,F.A.C.S. All complaints must be submitted in writing. You will not be penalized for filing a complaint. 

7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. 

If you have questions regarding this  notice or our health information privacy policies, pleased contact the office of Kimberly Lee, M.D. 

I hearby acknowledge that I have been presented with a copy of Kimberly Lee, M.D's notice of Privacy Practices.

 

 

 

 

 

 

By signing this agreement, we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than in a court.  Lawsuits are something that no one anticipates and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both patients and physicians. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California courts.  

By signing this agreement you are changing the place where your claim will be presented. You still can call witnesses and present evidence.  Each party selects an arbitrator (party arbitrators), who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both patients and physicians. This is because the time to conduct an arbitration hearing is far less than a jury trial. Further, both parties are spared some of the rigors of trial and the publicity, which may accompany judicial proceedings.  

Our goal, of course, is to provide medical care in such a way as to avoid any such dispute. We know that most problems begin with lack of communication. Therefore if you have any questions about your care, please ask us.