Client Form

UNDER HEALTH INSURANCE PORTABILITY & ACCOUNTABILIY ACT OF 1996 (HIPPA), YOU HAVE CERTAIN RIGHTS TO PRIVACY, WHICH ARE OUTINLED IN THE HIPPA FORM PROVIDED. THIS INFORMATION WILL BE USED TO:
PLAN, CONDUCT AND DIRECT YOUR TREATMENT AND FOLLOW-UP AMONG MULTIPLE HEALTH CARE PROVIDERS INVOLVED IN YOUR TREATMENT.
OBTAIN PAYMENT FROM THIRD PARTY PAYERS.
CONDUCT NORMAL HEALTHCARE OPERATIONS SUCH AS QUALITY ASSESSMENT AND PHYSICIAN CERTIFICATION.

YOU HAVE THE RIGHT TO REVIEW A NOTICE OF PRIVACY PRACTICES PRIOR TO SIGNING THIS CONSENT. THIS ORGANIZATION HAS THE RIGHT TO CHANGE ITS NOTICE OF PRIVACY PRACTICES FROM TIME TO TIME AND THAT YOU MAY CONTACT THIS ORGANIZATION AT ANY TIME TO OBTAIN A COPY OF THE NOTICE OF PRIVACY PRACTICES.

YOU MAY REVOKE THIS CONSENT IN WRITING AT ANYTIME.

THE PURPOSE OF THE AUTORIZATION AND RELEASE FROM IS FOR YOUR PROTETION. THE HIPPA ACT OF 1996 WAS CREATED WITH THE SOLE PURPOSE AND GOAL OF PROTECTING PATIENT’ MEDICAL RECORDS AND FINANCIAL INFORMATION. WE URGE YOU TO COMPLETE THIS FORM TO ALLOW US TO BETTER SERVE AND PROTECT YOUR PRIVATE INFORMATION. WE APPRECIATE YOUR ATTENTION TO THIS SENSITIVE MATTER. PLEASE BE SPECIFIC WHEN DESIGNATING YOUR CHOICES.

I AUTHORIZE THE STAFF OF MISSISSIPPI CENTER FOR PLASTIC SURGERY, PLLC TO RELEASE ANY MEDICAL INFORMATION TO THE FOLLOWING PEOPLE:

I AUTHORIZE THE STAFF OF MCPS, PLLC TO RELEASE ANY FINANCIAL INFORMATION TO THE FOLLOWING PEOPLE:

I AUTHORIZE THE STAFF OF MCPS, PLLC TO LEAVE LABORATORY AND RADIOLOGY TEST RESULTS ON MY VOICEMAIL A THE FOLLOWING TELEPHONE NUMBERS

Patient Responsibility

1. PATIENTS WHO CARRY INSURANCE SHOULD REMEMBER THAT PROFESSIONAL SERVICES ARE RENDERED AND CHARGED TO THE PATIENT AND NOT THE INSURANCE COMPANY. IT IS YOUR RESPONSIBILITY TO MAKE SURE YOUR BILL REMAINS CURRENT AND PAID.
2. EVEN THOUGH AN INSURANCE CLAIM IS FILED, YOU WILL RECEIVE A STATEMENT EACH MONTH IF THERE IS A BALANCE DUE. THE OFFICE CANNOT ACCEPT RESPONSIBILITY FOR COLLECTING YOUR INSURANCE CLAIM OR FOR NEGOTIATING A SETTLEMENT ON A DISPUTE CLAIM.
3. IF YOUR INSURANCE COMPANY HAS NOT PAID YOUR CLAIM IN SIXTY DAYS IT WILL BE YOUR RESPONSIBILITY TO PAY YOUR BALANCE OR ARRANGE A PAYMENT PLAN TO BE CERTAIN YOUR ACCOUNT STAYS CURRENT.
4. PATIENTS WITH INSURANCE POLICIES THAT COVER ONLY A PORTION OF THE TREATMENT MUST PAY THE DIFFERENCE BETWEEN ACUTAL CHARGES AND THE ANTICIPATED INSURANCE PAYMENT. THIS PAYMENT WILL BE REQUESTED AND IS DUE AT THE TIME OF SERVICE. A PRE TREATMENT DEPOSIT MAY BE REQUIRED.
5. PAYMENT FOR ALL CHARGES WHICH ARE NOT COVERED BY INSURANCE ARE DUE AND PAYABLE AT THE TIME OF SERVICE.
6. THE FOLLOWING PAYMENT METHODS WILL BE ACCEPTED: CASH, CHECK, MONEY ORDER, VISA, MASTERCARD AND AMERICAN EXPRESS. ANYONE WHO SUBMITS TW INSUFFICIENT FUNDS CHECKS WILL BE UNABLE TO WRITE CHECKS AGAIN IN THIS OFFICE.
7. RETURN CHECKS: THERE WILL BE A FEE OF $30.00 FOR EACH CHECK THAT IS RETURNED.
8. IF PATIENT IS UNABLE TO MAKE FULL PAYMENT OF THE PATIENT BALANCE WHEN DUE, PERIODIC PARTIAL PAYMENTS MAY BE APPROVED IN ACCORDANCE WITH CREDIT AND COLLECTION PROCEDURES AS AUTHORIZED BY THE BILLING MANAGER.
9. PATIENTS WITH UNPAID DELIQUENT ACCOUNTS OR ACCOUNTS WHICH HAVE BEEN WRITTEN OFF TO BAD DEBT MAY BE DENIED TREAMENT IF NOT MEDICALLY EMERGENT.
10. PLEASE UNDERSTAND THAT ANY ACCOUNT WHERE NO ATTMEPT OF PAYMENT HAS BEEN MADE WITHIN 60 DAYS WILL BE TURNED OVER TO A COLLECTION AGENCY AND YOU WILL ACCRUE FINANCE CHARGES, COLLECTION CHARGES AND ATTORNEY FEES. THE COLLECTION FEE WILL 35% OF YOUR ACCOUNT BALANCE
11. TO RECEIVE A COPY OF YOUR RECORDS THERE WILL BE A FEE
12. FOR A PATIENT REQUIRING DOCUMENTS TO BE COMPLETED BY THE DOCTOR OR HIS REPRESENTATIVE THERE WILL BE A FEE OF $35.00.
13. OVERPAYMENTS WILL BE REFUNDED TO THE APPROPRIATE PARTY, NORMALLY THE INSURANCE COMPANY OR THE GUARANTOR. PATIENTS REFUNDS WILL NOT BE PROCESSED UNTIL ALL ACTIVE OR PAST DUE ACCOUNTS ARE PAID IN FULL. REFUNDS OF LESS THAN $25 WILL NOT BE PROCESSED UNLESS SPECIFICALLY REQUESTED.
14. THE PHYSICIANS WILL NOT BE INVOLVED IN DISPUTES ARISING FROM THIRD PARTY CLAIMS.
15. WE CANNOT HOLD CHECKS OR ACCEPT POST DATED CHECKS.
16. IF YOUR APPOINTMENT REQUIRES CANCELLING, WE MUST BE NOTIFIED 24 HOURS IN ADVANCE OR THERE MY BE A $35 CHARGE FOR MISSING YOUR APPOINTMENT

I HEREBY ASSIGN ALL MEDICAL AND SURGICAL BENEFITS, TO INCLUDE MAJOR MEDICAL BENEFITS TO WHICH I AM ENTITLED. I HEREBY AUTHORIZE AND DIRECT MY INSURANCE(S), INCLUDING MEDICARE, PRIVATE INSURANCE AND ANY OTHER HEALTH/MEDICAL PLAN TO ISSUE PAYMENT CHECKS DIRECTLY TO THE MISSISSIPPI CENTER FOR PLASTIC SURGERY, ITS PHYSICIANS, AND/OR NURSE PRACTITIONERFOR MEDICAL SERVICES RENDERED TO MYSELF AND MY DEPENDENTS REGARDLESS OF MY HEALTH INSURANCE BENEFITS, IF ANY. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE

I HEREBY AURTHOIZE THE MISSISSIPPI CENTER FOR PLASTIC SURGERY TO FURNISH AND/OR RELEASE ANY INFORMATION NECESSARY TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENTS, AND TO PROCESS MY INSURANCE CLAIM ACQUIRED IN THE COURSE OF MY EXAMINATION OR TREATMENT, TO ALLOW A PHOTOCOPY OR ELECTRONIC IMAGE OF MY SIGNATURE TO BE USED TO PROCESS MY INSURANCE CLAIM FOR THE PERIOD OF LIFTIME. THIS ORDER WILL REMAIN IN EFFECT UNTIL REVOKED BY ME IN WRITING.

I HAVE REQUESTED MEDICAL SERVICES FROM THE MISSISSIPPI CENTER FOR PLASTIC SURGERY ITS PHYSICIANS AND/OR NURSE PRACTITIONER ON BEHALF OF MYSELF AND/OR MY DEPENDENTS, AND UNDERSTAND THAT BY MAKING THIS REQUEST, I BECOME FULLY FINANCIALLY RESPONSIBLE FOR ANY AND ALL CHARGES INCURRED IN THE COURSE OF TREATMENT AUTHORIZED. I FURTHER UNDERSTAND THAT FEES ARE DUE AND PAYABLE ON THE DATE THEY ARE RENDERED AND AGREE TO PAY ALL SUCH CHARGES IN FULL IMMEDIATELY UPON PRESENTATION OF THE APPROPRIATE STATEMENT. A PHOTOCOPY OR ELECTORINC IMAGE OF THIS ASSIGNMENT IS CONSIDERED AS VALID AS THE ORIGINAL.