I, the undersigned patient, hereby acknowledge and agree to the following terms and conditions associated with receiving services at Rapaport Plastic Surgery [David P. Rapaport, MD, FACS], hereinafter referred to as the "Practice."
Privacy and Confidentiality
Medical Records: I understand that the Practice will maintain my medical records in accordance with applicable privacy laws and regulations. My medical records may be shared with other healthcare providers involved in my care as needed and as required by law.
Medical Documentation: I understand that photographs and/or video recordings may be taken before, during, and after medical procedures for the purpose of medical documentation, tracking progress, and evaluating treatment outcomes. These images may become a part of my medical record.
Use of Information: I authorize the Practice to use my personal and medical information for treatment, payment, and healthcare operations, including but not limited to, appointment reminders, billing, and quality improvement activities.
Third-Party Disclosures: The Practice may disclose my information to third parties for purposes such as insurance claims, legal requirements, or when necessary for my treatment. The Practice will take reasonable measures to protect my information.
Marketing Communications: I understand that I may receive marketing communications from the Practice via email or other means. I have the option to opt out of these communications at any time.
Financial Responsibility
Payment Responsibility: I am responsible for all fees associated with the services provided by the Practice. Payment is due at the time services are rendered unless other financial arrangements have been made in advance.
Insurance: If applicable, I understand that it is my responsibility to provide accurate insurance information, and I am responsible for any deductibles, co-payments, or services not covered by my insurance plan. I also understand that for pathology and bloodwork, any billing inquiries should be directed to the laboratory. Furthermore, I acknowledge that it is my own responsibility to seek reimbursement for treatments rendered at the Practice.
Cancellation/No-Show Policy: I understand that I must provide the "Practice" Rapaport Plastic Surgery [David P. Rapaport, MD, FACS], with at least 2 business days of notice for appointment cancellations or rescheduling. Missed, rescheduled, or cancelled consultations without 2 business days' notice will incur a fee of $250.00. Missed, rescheduled, or cancelled treatment(s) without 2 business days' notice will incur a fee of $250.00.