In order to best communicate with our patients, we may use multiple methods to expedite service. By providing the information below, I agree that Dr. Clayton Frenzel/BodEvolve or one of its legal agents may use the information I provide to contact me via text, phone call, automated/artificial voice message, mail or email. Messages may be left via these communication methods unless specifically declined.

Other than you and your healthcare providers involved in your care, whom can we speak with about your health

I authorize the release of any medical information about me to Dr. Clayton A. Frenze/Bodevolvel, his assistants, or insurance company that is needed in the course of examination or treatments. Benefits to be paid to Dr. Clayton Frenzel P.A. or BodEvolve PLLC. I understand there is a $500 deposit to schedule self-pay surgery. Payment for office visits is required at time of service. For all procedures, advance payment is required two weeks prior to surgery.

The following questionnaire will help you measure your general level of daytime sleepiness. You are to rate the chance that you would doze offor fall asleep during different routine daytime situations. Answers to the questions are rated on a reliable scale called the Epworth Sleepiness Scale (ESS Each item is rated from 0 to 3 with 0 meaning that you would never doze or fall asleep in a given situation, and 3 meaning that there is a very high chance that you would doze or fall asleep in that situation.

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? Even if you haven't done some of these activities recently, think how they would have affected you.

Use this scale to choose the most appropriate number for each situation:

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

State and Federal guidelines require that physicians that have an ownership interest in a facility to which the physician may refer patients, disclose their affiliation.  In the interest of providing our patients with complete information, we are providing the names of the outside facilities where Dr. Clayton A. Frenzel may have an ownership interest.

  

Dr. Clayton Frenzel, P.A.     

1000 North Davis Dr. Suite B     

Arlington, TX 76012                                 817-342-0232    

 

BodEvolve, PLLC                

1000 North Davis Dr. Suite C                                   

Arlington, TX 76012                                   817-342-0232       

  

Keystone Anesthesia Partners, PLLC   

1000 North Davis Dr. Suite C                                   

Arlington, TX 76012                                   817-342-0232  

  

Texas Surgery Specialists                          

1000 North Davis Dr. Suite C                                   

Arlington, TX 76012                                    817-342-0232   

White Rock Medical Center(Peak Health Surgicare)

9440 Poppy Dr,

Dallas, TX 76208                                        972-954-3588

731 Plaza Blvd,

Coppell, TX 75019                                      469-451-5700

610 North Coit Road, Suite 2115                          

Richardson, TX 75080                                 972-954-3588

1190 North Haskell Avenue                                     

Dallas, TX 75244                                        214-821-2001

 

During your course of treatment with Dr. Frenzel, you may be referred to one of these facilities for medical services.  You have the right to choose the facility where you receive medical treatment/services, including the right to choose a facility other than the ones listed above.

 

By signing below, I acknowledge receipt of the above disclosure information.

 

Bariatric Contract for Compliance

I acknowledge and agree that upon consenting to and undergoing bariatric surgery, I will comply with the list below for the purpose of promoting the success of the bariatric surgery.

1.agree to be seen for regularly scheduled follow up appointments and be an active participant in my care in I

order to achieve my best outcome.

2. I will begin a fitness routine. I will build my endurance until I am able to exercise for a minimum of 30 minutes per day within the first 60 days.

3.| will follow all dietary guidelines recommended by Dr. Frenzel and/or his representatives (Nurse Practitioner, Physicians Assistant, dietitian, medical assistant, and staff members

4. If deemed necessary, I will participate in psychotherapy sessions with a licensed professional to resolve any psychological issues that may limit my successful weight loss.

5.| acknowledge that monthly support groups are available through either the practice or the facility where

6. I agree that in order for me to achieve the greatest degree of success with this surgery, I must strictly follow the guidelines as provided by Dr. Frenzel and his office.

7. As suggested by Dr. Frenzel and my insurance company, I agree that in order for me to achieve the greatest degree of success with bariatric surgery, | will not become pregnant for at least one year (12 months) following my procedure.

By signing this agreement, I acknowledge my understanding, agreement, and compliance with the stated items.

I hereby authorize the use or disclosure of my individual identifiable health information as described below. I understand that this authorization is voluntary. I understand that if the organization to receive the information is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations. This form must be completely

DR. FRENZEL AND HIS AFFILIATES WILL NOT RECEIVE FINANCIAL OR ANY KIND OF COMPENSATION IN EXCHANGE FOR USING OR DISCLOSING THE HEALTH INFORMATION DESCRIBED ABOVE.

DR. FRENZEL AND HIS AFFILIATES WILL NOT RECEIVE FINANCIAL OR ANY KIND OF COMPENSATION IN EXCHANGE FOR USING OR DISCLOSING THE HEALTH INFORMATION DESCRIBED ABOVE.

 I UNDERSTAND THAT MY HEALTH CARE AND THE PAYMENT FOR MY HEALTH CARE WILL NOT BE AFFECTED, IF I DO NOT SIGN THIS FORM.

 I UNDERSTAND THAT I MAY SEE AND COPY THE INFORMATION DESCRIBED ON THIS FORM IF I ASK FOR IT, AND THAT I RECEIVE A COPY OF THIS FORM AFTER I SIGN IT.  FURTHER, I UNDERSTAND THERE MAY BE A FEE FOR A COPY OF THIS INFORMATION.

I UNDERSTAND THAT THIS AUTHORIZATION WILL EXPIRE 180 DAYS FROM THE DATE SIGNED.

 I UNDERSTAND THAT I MAY REVOKE THIS AUTHORIZATION AT ANY TIME BY NOTIFYING THE PROVIDING ORGANIZATION IN WRITING, BUT IF I DO, IT WILL NOT HAVE ANY EFFECT ON ANY ACTIONS THEY TOOK BEFORE THEY RECEIVED REVOCATION.

 I UNDERSTAND THAT MY RECORDS ARE PROTECTED UNDER STATE AND FEDERAL LAW. I UNDERSTAND THAT SPECIFIC INFORMATION TO BE DISCLOSED MAY INCLUDE HISTORY OF DRUG AND ALCOHOL ABUSE, MENTAL HEALTH TREATMENT, AIDS OR ANY OTHER MEDICAL INFORMATION.

Under the terms stated herein, I hereby grant Dr. Clayton Frenzel/BodEvolve, its legal representative and assignees with Dr. Clayton Frenzel/BodEvolve authority and permission, the absolute right and permission to copyright and use, re-use, publish, and republish photographic portraits and/or pictures of me or in which | may be included, in whole or in part, from time to time, in conjunction with my own or fictitious name, or reproductions thereof in color or otherwise made through any media, including but not limited to: art; trade; print, broadcast, electronic advertising, internet advertising, brochures; posters; newsletter, newspaper, magazine articles; or any other purpose whatsoever.

I hereby waive any right to inspect or approve the finished product or products or any copy or printed matter or script that may be used in connection therewith or the use to which it may be applied. I understand the copy used may include a statement of my weight before and/or after my bariatric surgery.

I hereby release, discharge, and agree to hold harmless Dr. Clayton Frenzel/BodEvolve, its subsidiary, affiliates, agents, and legal representative or assigns, and all persons acting under Advanced Surgery permission or authority or those for whom Dr. Clayton Frenzel/BodEvolve is acting, from any claims or liability arising from the use of my image and/or any copy related to using my image.

I hereby release Dr. Clayton Frenzel/BodEvolve, its subsidiary, affiliates, agents, and legal representative or assigns, and all persons acting under Dr. Clayton Frenzel/BodEvolve permission or authority or those for whom Dr. Clayton Frenzel/BodEvolve is acting, from any monetary compensation, now or in the future, for the use of aforesaid portraits and/or photographs in the aforesaid manner of usage.

Ihereby agree that either I and/or Dr. Clayton Frenzel/BodEvolv can revoke this Release at any time in the

future upon written notice and when such written notice is delivered to the other party by US Postal Service, Certified Mail, Return Receipt Requested. Both parties hereby agree that this release will become null and void within 90 days of receipt of such written notice of revocation.

I hereby warrant that I am of full age and have every right to contract in my own name in the above regard. | state further that I have read the above authorization, release and agreement, prior to its execution, and that I am fully familiar with the contents thereof.

It is understood by both parties that this release will be in full force and effective for 100 years unless written notice of revocation of this document is made as specified above.

Purpose: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy. This disclosure is not intended to alarm or frighten you, but rather to make you better informed SO that you may give or withhold your consent to the proposed

Consent to Treatment: I voluntarily request Dr. Clayton Frenzel, as my physician, and such associates, assistants, nurses and other health care providers as deemed necessary or advisable, to treat my condition. I understand that it is my responsibility to actively participate in my care in order to maximize improvement in my condition.

Iunderstand that I may undergo extensive diagnostic tests and examinations during my treatment with Dr. Frenzel. If I am unable or unwilling to undergo such testing, my treatment plan may be revised and my condition outcome may be affected. During the course of treatment, I may be required to make frequent follow-up visits to review diagnostic test results. I will be required to personally attend office visits for appropriate care and treatment.

I agree to keep my physician and authorized associates apprised of any changes in my medical condition. Certain diagnostic tests, treatments, and drug therapies can be dangerous under certain medical conditions or medication use. Pregnancy is one such medical consideration and females must be certain to acknowledgethis condition prior to diagnostic imaging and initiation of any medication therapy. Female patients who become pregnant during the course of their treatment with Dr. Frenzel will notify their prescribing physician if they are on medication therapy.

Furthermore, I understand that no warranty or guarantee will be made to me as a result of any medication therapy, treatment or cure of my condition. I have the opportunity to ask questions about my condition and treatment, risks of non-treatment and the medication therapy, medical treatment(s) or diagnostic procedure(s) to be used to treat my condition, and the risks and hazards of such medication therapy, treatment(s) and procedure(s), and I believe I have sufficient information to give this informed consent.

I hereby consent to treatment.

Thank you for choosing Dr. Clayton Frenzel for your surgical/medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.

Our coordinators, both bariatric and cosmetic will do their best to get your surgical/medical services pre authorized by your insurance. If surgical/medical services are denied either prior to or after your procedure, the financial responsibility remains with the patient. WE CANNOT GUARANTEE THAT YOUR INSURANCE WILL APPROVE THE

PROCEDURE YOU ARE ATTEMPTING TO GET COVERED OR WILL MAKE PAYMENT.

PATIENT FINANCIAL RESPONSIBILITIES

The patient is ultimately responsible for the payment for treatment and care. We will bill your insurance for you. However, the patient is required to provide the most current and updated information regarding insurance. Patients are responsible for payment of copays, coinsurance, deductibles and all other procedures or treatment not covered by their insurance plan. Copays are due at the time of service Coinsurance, deductibles and non-covered items are due two weeks prior to your procedure. If your services are denied after billing the health insurance, you will have 30 days to pay after receiving the first statement. Patients may incur, and are responsible for payment of additional charges, if applicable. These charges may include a charge for returned checks in the amount of $30.00

By my signature below, I hereby authorize assignment of financial benefits directly to Dr. Clayton Frenzel/BodEvolve

I understand that I am financially responsible for charges not covered by this assignment.

I hereby assign and convey directly to Dr. Clayton Frenzel, P.A., BodEvolve LLC, AC Surgery Center LLC, Keystone Partners PLLC as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above-named healthcare providers, regardless of its managed-care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above-named healthcare providers to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above-named healthcare providers any and all Plan documents, summary benefit descriptions, insurance policy(s), and/or settlement information upon written request from the above-named healthcare providers or its attorneys in order to claim such medical benefits.

In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above-named healthcare providers any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tortfeasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above-named healthcare providers (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

I intend by this assignment and designation of authorized representative to convey to the above-named providers all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or medications provided by the above-named healthcare providers including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above-named providers) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, healthcare benefit plan, or plan administrator. The above-named providers as my assignee and my designated authorized representative may bring suit against any such healthcare benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider’s expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (healthcare reform legislation), ERISA, Medicare, and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original. I also herby authorize the release of any medical information about me to the Social Security Administration and Health Care Financing Administration or its intermediaries, and request payment of my medical insurance benefits to be paid directly to Dr. Clayton Frenzel, P.A., BodEvolve, LLC.

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.

Acknowledgement of Risks, Diet and Follow-Up for all Bariatric Surgeries

 

Risk Summary for Bariatric Gastric Surgery:

 

Death, Blood Clots, Gastric Leak, Bleeding, Organ Dehydration, Wound Infection, Abscess, Adhesion, Additional Surgery, Pneumonia, Nutrition problems, Food Intolerance, Inflammation of the esophagus/stomach and reflux, Constipation, Increased fertility, Hair loss, Loss of Muscle Mass

 

Benefits: 

 

Remission for type 2 diabetes, help prevent the risk of death associated with stroke, hypertension and myocardial infarction, blood pressure and cholesterol levels can return to normal, improve mental health, improve sleep quality and sleep apnea may resolve, improve joint pain, help with family planning and fertility

 

______

 

Diet, Pre-op, and Post-op: 

 

Pre-op: 

 

A specific diet is expected pre-op to shrink your liver that starts 2 weeks prior to surgery. This is 2-3 protein shakes a day and 1 small meal under 450 calories. If you have a high BMI you may be asked to start this as soon as the day after your consultation. 

This can be found on Page 5 of your book

 

Post-Op:

 

A very specific diet for Post op is described. Week 1 is a liquid diet that will consist of liquids that you can see through or clear. Examples include broth, water, jello, clear protein drinks

 

Week 2 is a full liquid diet that consists of protein shakes and cream soups. 

 

Week 3-6 will be a progression of soft foods to chewing. 

 

The entire diet is shown in the book on pages 21-24

**After Week 6 you will be expected to follow the diet for the remainder of your life. This will ensure the success of your surgery and keep you as healthy as you can be. This will also ensure that your surgery pouch will remain healthy. 

 

______

 

Long-Term After Care:

 

After-care post bariatric surgery is a lifelong commitment. You will have appointments on a regular basis for the first year, every 6 months the second year and then yearly afterwards. This is to ensure that you are not developing any issues or complications. You will have a schedule of x-rays and lab work to ensure the health of your pouch and that your vitamin levels are within range. This will also serve as a good reminder of healthy eating, exercise and requirements such as vitamins that often get forgotten the longer you are away from your surgery date.

 

 

 

 

I understand that as part of my healthcare, Dr. Clayton Frenzel/BodEvolve ("PROVIDER") originates and maintains health records describing my health history, symptoms, examination and tests results, diagnoses, treatment and any plans for future care or treatment. I understand that this information is utilized to plan my care and treatment, to bill for services provided to me, to communicate with other healthcare providers and in other routine healthcare operations such as assessing quality and reviewing competence of healthcare professionals and as required or permitted by law without my consent.

The PROVIDER'S Notice of Privacy Practices provides specific information and complete description of how my personal health information may be used and disclosed. I have been provided a copy of or access to the Notice of Privacy Practices and understand that I have the right to review the notice prior to signing this acknowledgment. I understand that the PROVIDER reserves the right to change the Notice of Privacy

I have been provided and have reviewed the PROVIDER'S Notice of Privacy Practices dated March 25,2011.

I give permission to Dr. Clayton Frenzel/BodEvolve to release my private health information to my PCP.

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.

Dr. Clayton A. Frenzel has adopted the following privacy policies:

 

USES AND DISCLOSURES

TREATMENT  

Your health information may be used by staff members or disclosed to other health care professionals for the sole purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedure will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

 

PAYMENT

Your health information may be used to seek payment from your health plan or from credit card companies that you may use to pay for services.  For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

 

HEALTH CARE OPERATIONS

Your health information may be used as necessary to support the day-to-day activities and management of BodEvolve. For example, information on the services you receive may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.

 

LAW ENFORCEMENT

Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

 

PUBLIC HEALTH REPORTING

Your health information may be disclosed to public health agencies as required by law.  For example, we are required to report certain communicable diseases to the state’s public health department.

 

OTHER USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION

Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization.  If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

 

ADDITIONAL USES OF INFORMATION

Appointment reminders-         Your health information will be used by our staff to send you appointment reminders by mail or to contact you by phone regarding appointment reminders.

Information about Treatments- Your health information will be used to send your information or the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

 

Individual Rights

You have certain rights under the federal privacy standards. These include:

-          The right to request restrictions on the use and disclosure of your Protected Heath Information

-          The right to receive confidential communications concerning your medical condition and treatment

-          The right to inspect and copy your Protected Health Information

-          The right to amend or submit corrections to your Protected Health Information

-          The right to receive an accounting of how and to whom your Protected Health Information has been disclosed

-          The right to receive a printed copy of this notice

 

BodEvolve Duties              

We are required by law to maintain the privacy of your Protected Health Information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Review Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations.  Whatever the reason for these provisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all Protected Health information that we maintain.

Requests to Inspect Protected Health Information           

As permitted by federal regulation, we require that requests to inspect and copy. Protected Health Information should be submitted in writing. You may obtain a form to request access to your records by contacting:

Dr. Clayton A. Frenzel, 1000 N. Davis Dr. Ste. B, Arlington, TX 76012. (817-342-0232)

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to 1000 N. Davis Dr. Ste. B, Arlington, TX 76012

 If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a complaint.

Effective Date

This notice is effective on or after March 25, 2011.