Wenjing Liu MD intake form

Patient Information
Name*

First NameMiddle InitialLast Name
Marital status
Social Security Number
Date of birth*

MonthDayYear
Birth sex*
Preferred language*
Ethnicity*
Race*
Patient contact information
Preferred contact method*
Preferred phone number*
Ok to leave a detailed message?*

YesNo
Home phone number
Mobile phone number
Work phone number
Email address*
Would you like to receive email notifications?*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code

Photographic Consent
In connection with the medical services that I am receiving from Wenjing Liu, M.D., I consent that photographs and / or videos may be taken of me before, during, and after treatments.
Please select one of the following:*

These photos or videos may be used for my medical records AND any print, visual, or electronic media including but not limited to medical journals, textbooks, education and marketing materials, public and private websites, social media, TV shows and magazineI opt out, and only allow photographs for my medical records
Signature*

Clear
Print Full Name*
Date*

MonthDayYear

Consultation Questionnaire
My three biggest concerns are

The discomfortTelling my spouse or othersThe costAnesthesiaPeople noticingThe scarsLooking unnaturalTaking time offOther
How soon are you interested in receiving your procedure or treatment?
Do you have any particular dates in mind?

MonthDayYear
Are you getting ready for a special event?

Insurance information

(you may leave blank if you are only having a cosmetic procedure)
Are you ONLY having a cosmetic procedure?*

YesNo
Primary insurance
Insurance company*
Policy number*
Group number*
Policy type*
Patient's Relationship to Policy Holder*
Policy Holder's Name*

First NameMiddle InitialLast Name
Policy Holder's Date of Birth*

MonthDayYear
Policy Holder's Birth Sex*
Policy Holder's Social Security Number
Policy Holder's Phone Number*
Billing address is the same as the patient's*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Primary insurance front of card

Cancelof
Primary insurance back of card

Cancelof
Secondary insurance
Do you have secondary insurance?*

YesNo
Insurance company*
Policy number*
Group number*
Policy type*
Patient's Relationship to Policy Holder*
Policy Holder's Name*

First NameMiddle InitialLast Name
Policy Holder's Date of Birth*

MonthDayYear
Policy Holder's Birth Sex*
Policy Holder's Social Security Number
Policy Holder's Phone Number*
Billing address is the same as the patient's*

YesNo
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Secondary insurance front of card

Cancelof
Secondary insurance back of card

Cancelof
I hereby authorize my insurance benefits to be paid directly to Wenjing Liu, M.D. I agree that I am responsible for copayments, deductibles, and non-covered services. I hereby authorize the release of pertinent medical information to insurance carriers for the purpose of billing.*

Clear
Print Full Name*
Date*

MonthDayYear

Primary Care Physician
Primary care physican name*
Primary care physician phone*
Primary care physician address*
Pharmacy information
Preferred pharmacy name
Preferred pharmacy phone
Preferred pharmacy address
Emergency contact information
Emergency contact name*
Emergency contact phone number*
Relationship*
Other information
Employer
Occupation
How did you hear about our practice?
Referring physician
Referring physician phone

Missed appointment and cancellation policy
In order to be respectful to the needs of other patients, our office requires a 24-hour notice of cancellation of your appointment. In the event that you miss or fail to cancel your appointments in a timely manner, a fee of $100 may be charged. This fee must be paid prior to scheduling future appointments.

You may call (949) 200-6838 and leave a message or email info@wliumd.com at any time when you realize that you will be unable to keep your scheduled appointment. If you arrive more than 20 minutes late, we may have to reschedule your appointment. Exceptions to this policy will be made on a case-by-case basis. Thank you for your understanding.
Signature*

Clear
Print Full Name*
Date*

MonthDayYear

HIPAA Acknowledgement and Notice of Privacy Practices
This summary of our privacy practices is a condensed version of our Notice of Privacy Practices. Our full-length Notice is available for viewing on our website or in the office.

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.

We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care of you, and the services and / or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

How will we use or disclose your information? Here are a few examples (for more details please refer to the complete Notice of Privacy Practices):
- For medical treatment
- For appointment reminders
- To obtain payment for our services
- To avert a serious threat to health or safety
- In response to requests arising out of lawsuits
If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you. These rights include:
- The right to inspect and copy
- The right to amend
- The right to an accounting of disclosures
- The right to request restrictions
- The right to a paper copy of this notice
- The right to request confidential communications
For more information about these rights, please see the detailed Notice of Privacy Practices.
Signature*

Clear
Print Full Name*
Date*

MonthDayYear

State of California Required Notices
Open Payments Database

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.
Please verify that you are human*
Should be Empty:

Patient Information

Patient contact information

Medical Information

Eye and facial history

Past surgical history

Additional information

Photographic Consent

Consultation Questionnaire

Insurance information

Primary insurance

Secondary insurance

Primary Care Physician

Pharmacy information

Emergency contact information

Other information

Missed appointment and cancellation policy

HIPAA Acknowledgement and Notice of Privacy Practices

State of California Required Notices