As the responsible party, I agree that all charges that are not directly paid by my insurance will be my responsibility.

Next Form:  General Medical History >

I acknowledge that the above information is true, correct and complete to the best of my belief.

Next Form:  Office Policies >

We would like to thank you for making an appointment with our office. It is important that you understand the procedures of our office regarding Surgery.

• You are responsible for getting referrals and· keeping them updated with our office. All records request from other physician’s records, and any other records required for the approval process.

• You must pay any copays, deductibles or deposits at your pre-operative appointment at our office prior to your surgery. We do not offer payment arrangements.

Please read carefully & sign acknowledgment.

• I hereby authorize A. JOSEPH CRIBBINS III, MDto furnish medical records &/or test results including HIV status, via fax or mail, to my referring doctor, insurance companies and to the doctor to whom I am referred concerning my illness or treatment. I will not hold A. JOSEPH CRIBBINS III, MD or its employees responsible for any misdirected records or correspondence. I authorize payment of all medical benefits to A. JOSEPH CRIBBINS III, MD

• An assistant surgeon or PA may be assisting with your surgery. The assistant surgeon might be out of network with all insurance companies.

• The office staff will notify you if there will be a deposit due for the assistant. If your insurance company pays the assistant surgeon's fee, the deposit will be refunded back to you. If your insurance company does not pay, we will keep the deposit and accept that as payment in full for the assistant surgeon. Refunds are given according to office policy and after all deductible, copays, coinsurance and claims have been paid. This amount is not included in out of pocket maximums.

• There is a $35.00 fee for completing Family Medical Leave or disability papers each time they are requested.

• I hereby certify that I have provided A. JOSEPH CRIBBINS, MD my current Insurance, address, phone numbers, and any other pertinent information. I also understand that failing to disclose this information could result in my insurance carrier not providing benefits for this service.

TO ALL PATIENTS: If for any reason you decide to cancel or change your surgery, a $250.00 cancellation fee will apply.

Notice of Physician Ownership

Dr. A. Joseph Cribbins III, MD has ownership interest in Baylor Scott & White Medical Center-Frisco, Texas. Dr. A. Joseph Cribbins III, MD has an ownership interest in Texas Health Center for Diagnostics & Surgery-Plano, Texas. I understand that my physician may refer me to one of these facilities for surgery. I also understand that I may speak with my physician about his financial relationship with the facility, and that I may ask my physician to provide my treatment at a facility where he or she has no ownership interest.

In our efforts to comply with HIPPA, we need to be certain that we guard your privacy according to your wishes when it comes to your family, friends and co-workers.

You must inform us, in writing, of any changes in your directives. This record takes effect September 1, 2003, and will be kept in your file with your acknowledgement of receipt of our Notice of Privacy Practices.

Next Form:  HIPPA Acknowledgement >

Notice of Privacy Practices

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.

This office may use and disclose medical and financial information related to your care that may be necessary now or in the future to facilitate payment by third parties for services rendered by us, or to assist with, aid in, or facilitate the collection of data for purposes. Such information may be released to insurance companies, HMO’s and PPO’s, managed care organizations, IPA’s, Medicare/Medicaid, or other governmental or third-party payers, or any organizations contracting with any of the above entities to perform such functions. Medical records may be delivered to a primary care physician or any other physician that is directly or indirectly responsible for your medical care or the payment thereof. This office will not use or disclose any of your medical and financial information for any purpose not stated above without your specific authorization. You may revoke your authorization at any time.

You may request restrictions on certain uses and disclosures. This office is not required to agree to a requested restriction. You have the right to receive confidential communications of your protected health information. You have the right to inspect copy and amend your protected health information. You may also request an accounting of disclosures of your protected health information from this office.

We are legally obligated to maintain the privacy of your protected health information, to provide you with this Notice of Privacy Practices, and to abide by its terms. We reserve the right to change our privacy practices and apply revised privacy practices to protected health information.

You may register a complaint with this office if you suspect that your privacy rights have been violated. We will investigate the complaint and inform you of the findings. No retaliation will be made against you by this office because you registered a complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services.

You may speak with the office Manager or Privacy Officer to obtain additional information regarding any questions you may have concerning this notice or to receive a printed copy of this notice. This Notice of Privacy Practices is effective as of April 14, 2003.

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