www.drjohnburroughs.com - Patient Intake/Medical History Form

Information & Financial Policies
Initial - I have read and agree to this statement. Initial
Thank you for choosing our practice to help with your surgical needs. The following policies have been developed to be fair to everyone including you, other patients waiting for surgery, surgery facilities, anesthesiology staff, our office staff, and your surgeon. We are committed to providing you with the best possible medical care. If you have medical insurance, we would like to help you receive the maximum allowable benefits. In order to achieve this goal, we will need your assistance and understanding of our financial policies. Please carefully review the following information and sign and/or initial ALL as there are circumstances when insurance patients also have cosmetic services and vise-versa. (e.g., a suspicious mole identified during a cosmetic consult)
Initial - I have read and agree to this statement. Initial
I understand I may view our HIPAA regulations policy. (Available by request)
Initial - I have read and agree to this statement.
Dr. Burroughs COSMETIC APPOINTMENT FEES: I understand there is $150 cosmetic consultation scheduling fee, which is not refundable. This fee may be used towards a cosmetic procedure- surgery specifically performed by Dr. Burroughs within 90 days of consultation. This fee cannot be used for insurance charges, Springs Aesthetics services, or retail products. Failure to show, arrival 15+ minutes late, or failure to cancel within 48 business hours prior to a scheduled appointment results in a rescheduling fee ($150 new consult, $75 follow up appointments).
Initial - I have read and agree to this statement.
COSMETIC NURSE APPOINTMENT FEES: I understand there is a $100 cosmetic consultation fee, which is not refundable. This fee may be used towards an injectable procedure performed within 90 days of consultation. Failure to show, arrival 15+ minutes late, or failure to cancel within 48 business hours prior to a scheduled appointment results in a rescheduling fee ($100 new consult, $50 follow up appointments). Thread lift scheduling incurs a 50% deposit of the quote total provided and must be performed within 60 days of consultation. Failure to show, arrival 15+ minutes late, or failure to cancel by 7 business days prior to the scheduled procedure appointment results in forfeiture of the thread deposit fee.
Initial - I have read and agree to this statement.
SPA APPOINTMENT FEES: I understand there is a $50 spa consultation fee, which is not refundable. This fee may be used towards a spa procedure/treatment performed within 30 days of consultation. Failure to show, arriving 10+ minutes late, or failure to cancel within 48 business hours results in a $50 rescheduling fee. None of these fees are applicable towards product purchases. For laser hair removal appointments, we require you shave within 24 hours of your appointment or pay an additional $50 shaving fee.
Initial - I have read and agree to this statement.
PRODUCT PURCHASES: I understand all product purchases are final (even if unopened) and no refunds/credits/exchanges will be issued. Consult, scheduling fees and deposits may not be applied to retail product.
Initial - I have read and agree to this statement.
ASSIGNMENT: I request the payments and insurance benefits be verified, authorized by and made payable to John R Burroughs, MD, PC on my behalf for services provided. This assignment will remain in effect until revoked by me in writing. A photocopy of this authorization shall be considered as effective and valid as the original. In the event that my account is turned over to a collection agency, I agree to pay all costs for the collections agency and I understand that failure to do so may result in my no longer being a patient at this office.
Initial - I have read and agree to this statement.
CO-PAY/CO-INSURANCE/DEDUCTIBLE: I understand that it is my responsibility to provide my valid insurance cards and information so that my primary and secondary insurances may be billed on my behalf. I accept responsibility for any assigned co-payments, coinsurance and deductible amounts by my primary and/or secondary insurances. Tertiary insurance billing remains my responsibility.
Initial - I have read and agree to this statement.
WAIVER OF SERVICES: It is my responsibility to ensure that I obtain any and all insurance referrals and authorizations that may be required, as per my insurance plan, for the services that I receive at Springs Aesthetics. If this was required but not obtained, I understand I will be financially liable for payment of the services that I receive to Springs Aesthetic.
Initial - I have read and agree to this statement.
INSURANCE-COVERED SURGERY SCHEDULING: Scheduling of surgery, per my insurance plan specifics, may require my cost-share and/or deductible be paid in full prior to scheduling surgery. I authorize Springs Aesthetics to contact my insurance to obtain my payment responsibility.
Initial - I have read and agree to this statement.
SURGERY PROCEDURE REVISION FEES: Very rarely, after complete healing from surgery or procedure(s), results may not be as expected or there could be unwanted issues. No guarantee of surgical or procedure success can ever be made and complications, though not anticipated, have been known to occur with operations/procedures despite safety precautions. If Dr. Burroughs and I both agree that cosmetic revision (surgical or procedural) would likely be beneficial, then there is a variable fee to cover costs such as suture, other supplies, implant costs, and office time. If I wish to have revision or additional surgery at an outside facility then additional facility/anesthesia fees will apply. If revision surgery is needed, that is medically necessary (not cosmetic), then my insurance will be billed for these services if I wish to proceed. Cosmetic concerns are never billed to insurance.
Initial - I have read and agree to this statement.
ADDITIONAL MEDICAL PAYMENTS: In addition to Springs Aesthetics' fees, there are separate fees from surgery facility, lab, hospital, anesthesia, and/or other providers required for medically-indicated surgery or procedures. It is my sole responsibility to contact these entities as needed for their payment requirements. These costs are separate from any payments made to Springs Aesthetics, John R Burroughs MD PC.
Initial - I have read and agree to this statement.
RELEASE OF INFORMATION: I authorize the holder of my medical information pertaining to my healthcare and/or treatment to release any and all information to the requesting or referring entity, as necessary, this includes the Centers for Medicare and Medicaid Services, and its agents, my insurance carrier(s), and/or other entities for benefit determination and/or financing/payments for myself and/or my dependents. I authorize John R Burroughs, MD, PC to release information concerning my diagnosis and treatment plan to other provider(s), involved with my healthcare after each visit, as necessary. I may be required to sign additional releases to grant another entity access to such information.
Initial - I have read and agree to this statement.
REQUESTS FOR INFORMATION: Should I receive any requests from my insurance company regarding services that I have or plan to receive by this office, I will respond to that correspondence immediately so that any outstanding claims on my account can be processed and paid.
Initial - I have read and agree to this statement.
SELF-PAY: Self-pay balances are due, in full, as per the applicable specifics of planned procedures or surgery and will be provided to me.
Initial - I have read and agree to this statement.
WORKERS' COMPENSATION: I will provide written approval/authorization from my Workers' Compensation carrier at my initial visit. If the claim is involved in court litigation, Springs Aesthetics will not hold our claims or wait for any lien settlements to resolve before payment to our office is made. Private medical insurance will be billed. If the workers compensation claim is denied, I will be responsible for payment in full immediately.
Initial - I have read and agree to this statement.
RETURNED CHECKS: I understand I will be responsible to pay a fee of $35.00 plus bank-assigned service charge within 30 days of notification.
Initial - I have read and agree to this statement.
REFUNDS: I understand that refunds incur a 5% fee. Product purchases are final and services/procedures received are not applicable for refund as there can be no guarantee regarding results obtained given individual differences and responses to product treatments/surgery/procedures.
Initial - I have read and agree to this statement.
RIGHT TO REFUSE CARE: Springs Aesthetics reserves the right to refuse further care to me until my debt is settled and any outstanding balances on my account are paid in full as a result of a returned check. Furthermore, Springs Aesthetics reserves the right to refuse any future payments made by check. Springs Aesthetics may also refuse further care for other reason(s) (e.g., non-compliance, misbehaviors...). In accordance with state guidelines, a patient/client may be discharged from the practice following three (3) no-shows in a one-year period (365 days).
Initial - I have read and agree to this statement.
INSURANCE APPOINTMENT NO SHOW/LATE CANCELLATION POLICY: Failure to show, arrival 15+ minutes late, or failure to cancel by 48 business hours prior to a scheduled appointment (new or follow-up) results in a $75 charge.
Initial - I have read and agree to this statement.
PHOTOGRAPHY & RESEARCH:I consent to medical photography and/or video for medical documentation, research, and educational purposes. The photos taken will be stored as part of the patient's medical chart for reference and treatment tracking. These may be used for: obtaining insurance authorizations; educational seminars; medical articles; newsletters to current and prospective patients; and doctor letters. These remain the property of Springs Aesthetics. Dr. Burroughs, a former surgical professor, is an active educator, published physician, international speaker, and clinical researcher (mostly non-identifying, general data collection). Visual media enables him to teach other medical professionals. Images and videos used, outside chart documentation, will be cropped/edited to avoid unwanted recognition. Springs Aesthetics respects the privacy of his patients, and identifiable visual media will not be used without consent. A separate itemized permission release for visual media is available by request. I hereby grant permission to use non-identifiable treatment data for studies. I understand that Dr. Burroughs attempts, to the full extent possible, to adhere to the World Medical Association's Declaration of Helsinki-Ethical Principles of Medical Research (www.wma.net).
Social Media, Website, and Digital/Print Release: Please check one of the following regarding the use of your photos on social media, website, and/or digital/print materials for the office. (Please select a choice)
Initial - I have read and agree to this statement.
PAPERWORK (e.g., FMLA) FEE: $35 administrative fee, per incident, for FMLA, work-related, or other non-health insurance paperwork.
Initial - I have read and agree to this statement.
PRIVACY POLICY: I have been made aware of the privacy policy of Springs Aesthetics, John R Burroughs, MD, PC and the HIPAA Compliance Patient Consent Form - Notice of Privacy Practices. Request and check here: _for a copy.
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