Patient Information Form

I certify that the personal, demographic, and medical information I have provided is accurate, complete, and true. I authorize New Age Aesthetics & Wellness, PLLC (“New Age”) and any associates, assistants, and other health care providers it may deem necessary, to treat my condition. I understand that no warranty or guarantee has been made of a specific result of care. I agree to actively participate in my care to maximize its effectiveness.

I give my consent to New Age to retrieve and review my medication and medical history. I understand that this will become part of my medical record. I acknowledge that I have had the opportunity to review the Notice of Privacy Practices of New Age, which is displayed for public inspection at its facility and on its website. This Notice describes how my protected health information may be used and disclosed, and how I may access my health records. I authorize New Age to release my Protected Health Information (medical records) in accordance with its Notice of Privacy Practices. This includes, but is not limited to, release to my referring physician, primary care physician, and any physician(s) I may be referred to. I also authorize New Age to release any information required in obtaining procedure authorization. I understand that New Age will not release any information required in obtaining procedure authorization. I understand that New Age will not release my Protected Health Information to any other party (including family) without completing a written “Patient Authorization for Use and Disclosure of Protected Health Information” form, available at it’s facility and on it’s website. In the event that I am asked to provide a urine, saliva, or blood sample, I voluntarily seek laboratory services and herby consent to provide a urine, saliva, and/or blood sample as requested. I have the right to refuse specific tests but understand that this may impact my treatment. This agreement can be revoked by me at any time with written notification and is valid until revoked.

Payment in full is expected at the time of treatment. Please note that in the event that you fail to make payment when due, this account will be referred to the collection agency for collections. In that event, the contingency fee assessed by the collections agency will be added to the principal and interest due. You will be additionally liable for attorney fees. Both collection agency fees and attorney fees will increase the balance you owe.

As patients consider cosmetic procedures, they frequently have questions related to the various payment options for those procedures. We hope the following information will be helpful.

• Prescription medications: You may receive a prescription medication that is necessary for certain procedures and treatments. These are separate expenses which are often covered by your medical insurance. You may be charged an additional fee for certain medications administered during your treatment, such as nitrous oxide or Dsuvia.
• Payment Options: We provide several payment optionsincluding case, credit card (Visa, Mastercard, Discover, American Express), CareCredit, Cherry, and Key Bank Credit Financing. A combination of payment options is welcome. We DO NOT accept personal checks.
• Payment for Services: Payment is typically required at the time of treatment for most of our services and treatments. Exceptions to this included certain multi-day treatments which require payment for the series of treatments to be paid at the time of the initial treatment or surgical procedures which require advanced payment for scheduling and preoperative evaluation. Please see the financial policies for those specific procedures and surgeries.
• Cancellation & No-Show Policy: A $100 cancellation fee will be charged to your credit card for all non-surgical treatments and procedures that are cancelled within 24 hours of the scheduled procedure or in which you do not show up for the scheduled procedure. Separate specific policies exist for certain multi-day treatments and surgical procedures. Please see the financial policies for those specific procedures and surgeries.
• Return Policy: Packages and pre-paid treatments are good for 1 year after date of purchase. If for some reason, you are not satisfied with an un-rendered, pre-paid service, the remaining balance can be used towards other services at New Age Aesthetics and Wellness. Because of the nature of our medical grade and prescription skin care products we cannot return products that have been opened.
• Rescheduling Policy: If you need to reschedule your non-surgical procedure or treatment, please do so prior to 24 hours from your scheduled date and time. Failure to do so will result in a $100 cancellation fee charged to your credit card.
• Delinquent accounts: Accounts that become delinquent for non-payment for more than 30 days will be subject to collections services. Accounts that are turned over to a collection agency will be charged court costs and reasonable attorney fees for collection of all past due accounts owed plus interest thereon at 10% per annum on all amounts outstanding. If you have a payment problem, please call our office to discuss remedies to avoid additional charges and/or collections action.

I accept financial responsibility for all charges for treatment. I have read, understand, and accept the provisions described in this financial policy statement. I authorize the medical providers of New Age Aesthetics and Wellness and the staff to use information that I provide for the purpose of establishing an account for billing. I authorize New Age Aesthetics and Wellness to bill me for services, either planned for a future date or on the date those services were performed. A copy of this authorization shall be considered as valid as the original. In the event of any litigation arising from my treatment, I agree to submit the case to arbitration.

I have read and understand the terms of this Financial Agreement.

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

New Age Aesthetics and Wellness understands and agrees that patient confidentiality can be an integral part of patient care. Under the Health Insurance Portability and Accountability Act (commonly, HIPAA), all health care providers must maintain as confidential your protected health information, or PHI. Your PHI can include your name, address, social security number, email address, telephone number, date of birth, driver's license number, and medical record number. Health care providers must also provide patients with notice of the legal duties incumbent upon health care providers and their privacy practices so that the health care providers avoid any accidental or inappropriate disclosure of your PHI.

In February 2009, The American Recovery Reinvestment Act (ARRA or more commonly, the "Stimulus Bill") made some significant modifications to the HIPAA Privacy and Security Rules dealing primarily with the protection of your PHI in all media (meaning paper files and electronic storage). In addition, the Stimulus Bill introduced some new terminology - "Personally Identifiable Information" or "PII" along with penalties and mitigation associated with any violations and/or breaches of PHI or PII.

Personally Identifiable Information (again, the PII) is defined as any patient's first name or first initial and the last name in combination with any one or more of the following data elements belonging to that patient: social security number, driver's license number or ID card number, account number, or credit/debit card number in combination with any required security code or access code or password that would permit access to the patient's financial account.

New Age Aesthetics and Wellness uses health information about you for treatment purposes, to obtain payment for treatment it has provided to you, for internal administrative purposes, and to evaluate the quality of care you receive. In addition, as part of your ongoing treatment, health information may be shared with other health care providers (for example, certain medical specialists) to whom you are referred to or from whom you were referred to New Age Aesthetics and Wellness. Such information may be shared by paper mail, electronic mail, facsimile, or other methods.

Further, New Age Aesthetics and Wellness may disclose your PII (in whole or in part) without your authorization under certain circumstances. For example, subject to specific requirements, we may disclose your PII without your authorization for public health purposes such as reporting communicable diseases, birth, death, injury, or child abuse or neglect; for auditing purposes; for research studies; for worker's compensation claims; and for emergencies. We will also provide information when required to do so by law enforcement authorities or by court authorities. Contact with you may also take place in the form of an appointment reminder, prescription refills, test results, etc.

When other situations arise, we will ask you for your written authorization before using or disclosing any of your Pll. If you choose to sign an authorization to disclose some or all of your PII, you may later request to revoke either all or part of the authorization.

As the patient, you have the right to see and receive a copy of all information that is contained in your medical record (chart) at this office, with the following exceptions: psychotherapy notes; information compiled in reasonable anticipation of civil, criminal, or administrative litigation or enforcement proceedings; and protected health information if it is subject to protection under other applicable law. If New Age Aesthetics and Wellness denies your right of access, you are entitled to have that determination reviewed if the reason for the denial was one of the following: a health care professional has determined that access to the information is reasonably likely to endanger the life or safety of you or another person; or the protected health information refers to another person and access to the information is reasonably likely to cause harm to that person. If New Age Aesthetics and Wellness denies your right of access, you will not be entitled to have that determination reviewed if the reason for the denial was one of the following: the protected health information is excepted from the right of access under applicable law; or the protected health information was obtained from someone other than the health care provider under a promise of confidentiality.