Your Information. Your Rights. Our Responsibilities.

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.

Your Rights - You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices - You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures - We may use and share your information as we:

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights.

This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record.

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record.

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communication.

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share.

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request,
  and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our
  operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information.

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with,
  and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any
  you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12
  months.

Get a copy of this privacy notice.

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper
  copy promptly.

Choose someone to act for you.

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about
  your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated.

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in
the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in
your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

• Treat you-We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an
  injury asks another doctor about your overall health condition.
• Run our organization-We can use and share your health information to run our practice, improve your care, and contact you when necessary.
  Example: We use health information about you to manage your treatment and services.
• Bill for your services-We can use and share your health information to bill and get payment from health plans or other entities. Example: We
  give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and
research. We have to meet many conditions in the law before we can share your information for these purposes.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

• Help with public health and safety issues. We can share health information about you for certain situations such as:
  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety
• Do research. We can use or share your information for health research.
• Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
• Address workers’ compensation, law enforcement, and other government requests. We can use or share health information about you:
  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services
• Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you
  may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available
upon request, in our office.

* We never market or sell personal information*

FORREST P. WALL, MD, FACS * THE PLASTIC SURGERY CENTER AND WALL MEDISPA - NEW PATIENT

The primary goal of our physicians is the provision of quality patient care. This goal can be accomplished through sound fiscal management, the practice of keeping costs contained, and having the cooperation of our patients implementing the following policies.

Please review this document thoroughly and sign below. This will become part of your file.

CANCELLATIONS

Our goal is to provide quality medical care and in order to do that, we had to implement a cancellation policy. The policy enables us to better utilize available appointments for our patients. When scheduling an appointment credit or debit card information must be available. Please call our office immediately if you find you cannot keep your appointment. Cancellations of scheduled appointments must be communicated to our office at least 24 hours prior to the scheduled appointment time. For your convenience you may leave a message of cancellation on our voice mail system. Monday appointments must be cancelled by noon of the preceding Friday.

In the event that appointments are not cancelled with 24-hour notice, patients will pay a $35 deposit at the time of scheduling for future appointments with our aesthetician and Nurse Practitioner.

Our massage therapist requires a deposit of $50 that is due at the time of scheduling. Any appointment not cancelled with a 24-hour notice will forfeit their deposit.

Appointments not cancelled with a 24-hour notice for the physician will forfeit their $100 consultation fee that was collected at the time of scheduling.

THESE CHARGES ARE EXCLUSIVELY YOUR RESPONSIBILITY.

COSMETIC SURGERY – Cosmetic procedures require a 20% non-refundable deposit at the time the surgery is scheduled. 2-3 days prior to the surgery date, the remainder of the physician’s fee is required to be paid in full.
This is only payable in the form of cash, cashier’s check, major credit cards or money order within a week of surgery.

COSMETIC SURGERY CANCELLATIONS – Surgery scheduling requires careful planning and coordination between our office, the surgery center and their operating room staff, as well as the anesthesiologist, if applicable. Therefore, please understand the importance of respecting our 48-hour cancellation policy. Surgeries cancelled more than 48-hours prior to the surgery date that are rescheduled within 5 business days will be allowed to apply the 20% non-refundable deposit towards the new surgery date. Surgeries cancelled less than 48 hours in advance will forfeit the deposit. If there is a balance over the non-refundable deposit amount you will need to request a refund within 1 year of cancelling the surgery. After 1 year has passed the balance will be forfeited.

ASSISTANT SURGEON FEES – Your physician may elect to use the services of an assistant surgeon. Although his fee will appear on your monthly statement, you will not be responsible for payment of this fee. This will be billed to your insurance carrier, and assignment accepted.

INSURANCE CLAIMS – The benefits paid by insurance companies for plastic surgery vary greatly from carrier to carrier and plan to plan. Therefore, we make every effort to determine in advance if insurance coverage exists. We will obtain your benefit information such as deductibles, coinsurance and out of pocket expenses. This will determine the amount, if applicable, that will be required to be collected prior to scheduling your procedure. We do this because we believe you need to be as informed as possible before surgery. We know you realize that you are ultimately responsible for the full payment of your account, but we have found that our knowledge and experience can be an important factor in assisting you to collect your maximum benefits.

PATIENT ACCOUNT BALANCES – You will receive monthly statements showing the patient balance and insurance balance, if any. Payments are required monthly on any patient balance. If you are unable to pay your bill in full, we will be happy to arrange a comfortable monthly payment plan with you.

PRODUCT GIVEAWAY RECEIPEINTS – If you are the winner of a product due to a giveaway hosted by our office you will have 6 months from the date of notification or the office’s receipt of product to pick up the product as they have expiration dates. Thank you for your understanding.

The Plastic Surgery Center LLC strives to provide excellent health care. We will only release information concerning you to those that are necessary and/or if we have your permission. Thank you for choosing our practice to provide you medical care. Please feel free to inquire about anything we can assist you with.

Please sign that you have read and agree to our Business Policy as stated above.

I hereby irrevocably consent to and authorize the use and reproduction by the American Society of Plastic Surgeons (ASPS) and its affiliates, or anyone authorized by them, of any and all photographs, electronic images or video footage of me taken by ASPS, or that ASPS has in its possession, provided either by or by a third party (collectively, Images) for the purpose of informing the medical profession and the general public about plastic surgery and plastic surgery procedures and techniques without compensation to me. Such use shall include, but not limited to, distributing the images via print, visual, and electronic media, specifically including the ASPS website and social media sites such as YouTube, Facebook, and Twitter. The images (including any photographic negatives) shall be the sole property of ASPS. ASPS also shall have the right to use my name in connection therewith if it so chooses.

I hereby waive any right to inspect or approve the finished product, photograph, video, DVD, CD-ROM or matter that may be used in conjunction therewith or to the eventual use that it might be applied.

I hereby release, discharge, and agree to hold harmless ASPS and its affiliates and their respective representatives, assigns, and employees, and any person acting under their permission or authority, from and against any claims whatsoever in connection with the use of my Images and name the reproduction thereof as stated above, including any claim for payment in connection with distribution or publication of the video and/or photographs.

I hereby warrant that I am over the age of twenty-one years of age, and competent to contract in my own name insofar as the above is concerned.

I have read and understand the foregoing release, authorization and agreement, before signing my name below, and enter into it knowingly and voluntarily.

This Authorization is valid for two (2) years if effective dates are not specified and may be revoked at any time by delivering a signed Restriction Request Form with the original signature to our business office at:

385 Bert Kouns Ind. Loop, Bldg. 100 Shreveport, LA 71106

Release of the information may be governed by additional laws. I understand and agree that this information will be disclosed only if I place my initials in the applicable space next to the type of information:

I understand that providing my authorization is voluntary. I need not sign this Authorization for Release of Protected Health Information to continue to receive healthcare treatment from Forrest P. Wall, M.D. I understand that I may revoke this authorization, in writing, at any time except to the extent that disclosure was made prior to the time that I revoked this authorization. I further understand that I may inspect and receive copies of the information to be disclosed.

I understand that the health records and information disclosed or some portion thereof, may be protected by the Federal Health Insurance Portability and Accountability Act (“HIPAA”). I further understand that it is possible that the information described above may be re-disclosed by the recipient and may no longer be protected by HIPAA. I further understand that my records may be protected under state law and, if so, cannot be disclosed without my written consent unless otherwise provided for in the law and/or regulations.

My signature below acknowledges that I have read, understand, and authorize the release of the information described above.

I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. I CONSENT TO THE PHOTOGRAPHS TAKEN TO BE USED FOR MEDICAL, SCIENTIFIC, OR EDUCATIONAL PURPOSES, PROVIDED THE PICTURES DO NOT REVEAL MY IDENTITY.