You will now be directed to several screens where you will be given a chance to read and agree to agreements pertaining to your consent to treatment at STARS Plastic Surgery including financial responsibility, privacy policy, use of medical imagery, consent to obtain medical information and designation of authorized representative.

Privacy policy and release of information

Regarding usage of all forms of communication (mail, email, phone, fax, text messaging): there are risks that confidential information may accidentally be transmitted to people not authorized to receive such information.  Although STARS Plastic Surgery, "practice", institutes mechanisms available to avoid such risks, I am aware of the potential for breach.  I hereby authorize the practice to release my medical information via the forms of communication detailed above to any referring physician, hospital, treatment facilities and other persons for the purposes of diagnosis and treatment.  I further authorize the practice to release my name and address to other parties for the sole purpose of receiving medically related information via the above means of communication. In accordance with the federal government privacy rules implemented through the HEALTHCARE PORTABILITY ACT OF 1996 (HIPAA), in order for your physician or staff to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so.  In the event of a medical emergency, the law stipulates that these rules maybe waived.  I authorize the practice to release my medical information concerning my medical care, verbally or in writing as set forth above with the exception to the following individuals detailed below.  

Financial responsibility statement

STARS Plastic Surgery appreciates the confidence you have shown in choosing us to provide for your health care needs. STARS Plastic Surgery is a non-participating, out-of-network provider to some health insurance carriers and it is ultimately your responsibility to find out if we are part of your coverage network. Services rendered by STARS Plastic Surgery will be your full financial responsibility. If you are out-of-network, or if your procedure is not medically necessary, payment for services rendered is expected in full at the time of your visit or prior to your operation. As a courtesy, we will submit a claim to your insurance carrier and you will be refunded the reimbursed amount.  I am aware my insurance contract is between me and my insurance company and I will be billed by my provider for any services rendered not payable.  You are ultimately responsible for any unpaid charges. It is in your best interest to know and understand your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. By seeing a non-participating, out-of-network provider, your insurance company may reduce or deny payment or subject you to a higher co-pay and/or deductible. As this is a contract you hold with your insurance company, we are unable to project what they will or will not pay. While we are willing to work with you, we are not liable for any reduction of payment from that company based on your contract with them.   I also authorize STARS Plastic Surgery to use my medical information in discussion with my insurance company (or their agents) regarding healthcare, advice, treatment or supplies provided to me. This information will be used for the purpose of evaluating and administering claims of benefits.

Authorization to request medical records

I authorize STARS Plastic Surgery to request medical records on my behalf. I understand the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to STARS Plastic Surgery. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Consent for use of medical imagery

Medical Imagery (still photographs, video of your body and/or audio recordings) may be taken of you while you are undergoing evaluation and/or treatment. This imagery may become a part of your medical record. As part of your medical record, your privacy concerning this imagery is protected by the Privacy Act of 1974 (title 5, United States Code, section 552a), Public Law 104-191, the Health Insurance and Portability and Accountability Act of 1996. This imagery procedure is used to assist with medical decision making. STARS Plastic Surgery also seeks your consent to use the imagery for additional purposes such as but not limited to education, medical examinations or certifying boards, medical publications and materials to educate other patients with similar problems or interested in a similar procedure. This imagery may have identifying marks or features unrelated to your condition. I understand that I can request, that any time, that the recording or filming be stopped. I also understand that I can revoke my consent at any time in writing to STARS Plastic Surgery. Withdrawing my consent will apply to recordings or filmings from that point onwards but will not impact any videos or imagery previously published. I understand that I will not be compensated for use of my imagery.

Designation of STARS Plastic Surgery as an authorized representative

An Authorized Representative is a person you authorize to act on your behalf, in pursuing a claim or an appeal of a denied claim. This authorization may be either (1) granted for a particular event or date of service, after which time the authorization approval is revoked, or (2) granted for any present or future claim for health care benefits you may have. Designations of Authorized Representative status granted for a particular event or date of service are most appropriate when being granted to a health care provider or an attorney that may be representing you in connection with a claim. Designations of Authorized Representative status for any present or future claim for health care benefits are more appropriately made to family members or other trusted persons who you may wish to authorize to assist you in the future with health care claim matters. I hereby appoint STARS Plastic Surgery as an Authorized Representative, to act on my behalf in the filing or pursuance of claims and pursuance of appeals in connection with any date of service and any other pertinent information available on any present or future claim for health care benefits. I understand that as a result of this authorization, my medical insurance carrier may disclose and release information concerning benefit eligibility, claim status, or claim approval or denial reasons in connection with the above referenced health care claims to the individual named above. This designation is subject to revocation at any time by the designator except to the extent that my medical insurance carrier has taken action in reliance on this designation before they knew of the revocation. If not previously revoked, this designation will terminate on: Indefinite or until revoked.

By signing below, I, {name}, agree or attest to the statements above as I have indicated.

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