AUTHORIZATION: I request payment of authorized benefits be made on my behalf. I assign the benefits payable for services to the physician OR organization furnishing the services and authorize such physician OR organization to submit a claim to my insurance carrier OR Medicare for payment. I consent to have my protected health information released to insurance carriers OR the Centers for Medicare & Medicaid Services and it agents OR the Social Security Administration or its intermediaries OR Any Agency, group or person(s) necessary to secure treatment, payment or business operations by the physician or organization. *For and in consideration of services rendered and to be rendered by the above listed medical provider, I hereby guarantee payment of all charges incurred for this account. *The patient or his/her representative recognizing the need for health care, consents to the above listed medical provider rendering service as ordered by the physician, including medical or surgical treatment, laboratory procedures, X-ray exams or other services rendered under the general and specific instructions of the physicians. *I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct and that Plastic Surgeons of Lexington has provided me a copy of its Notice of Privacy Practices, which provides a detailed description of uses and disclosures allowed, as well as other rights I have regarding my protected health information:
Welcome to Plastic Surgeon's of Lexington. We are glad you've chosen us to provide you with your health care. Built on a tradition of service and excellence, or mission is to deliver the safest, highest quality, and most technologically advanced techniques with empathetic and compassionate care.
Insurance: We accept assignment and participate in most insurance plans. If you are unsure if we are in your insurance network, please check with your insurance company. Knowing your insurance benefits is your responsibility. Please contact your insurer with any questions you may have regarding your coverage to receive the maximum benefit.
Patient Payment: All copayments are to be paid at the time of service. Any charges that go toward your deductible will be payable by you.
I, (enter name below) , understand that as part of my healthcare, Plastic Surgeons of Lexington, PLLC originates and maintains health records describing my health history, symptoms, examination, and test results diagnoses, treatment, and any plans for future care or treatment. An electronic copy of your medical records is available upon request.
I, (enter name below), understand that Plastic Surgeons of Lexington may use my photo for the study of medical treatments and procedures. I give Plastic Surgeons of Lexington permission to take and use my photo, while maintaining my anonymity.
I have read the Notice of Information Practices and authorize Plastic Surgeons of Lexington to disclose my protected information to the following person(s):
I, further understand that I retain the right to revoke this authorization in writing. I fully understand and accept the terms of this authorization.