Insurance Information (If Applicable)
If HMO Plan, please contact your primary physician for a referral
If HMO Plan, please contact your primary physician for a referral
Please bring insurance card(s) and photo ID to your consultation
Medical / Surgical History
Do you take recreational drugs?
Review of Systems
Do you currently, or have you had, medical problems with:
If you have any other medical problems not listed please explain:
I voluntarily give my consent to authorize photographic and/or video documentation for use in the medical record-keeping professional journals, medical books or in the interest of medical education, research or other professional purposes. In accordance with Privacy Practices strictly upheld by the ADVANCED FACIAL PLASTIC SURGERY CENTER, it is specifically understood that I will never be identified by name nor any private person information disclosed in association with my medical photographs.
Please note that late cancellations within 24 hrs of your appointment or failure to appear for an appointment will incur a $75 cancellation charge for the physician and facial appointments; and $100 for the laser service appointments. Late cancelations or noshows for surgical package appointment will forfeit that portion for the package. Insurance will not cover charges for no-show, late-cancellation fees. We gratefully appreciate your consideration.
I understand that I am financially responsible for any charges not paid by medical insurance and agree to pay these charges. I authorize the release of my medical information to applicable health insurance carrier(s). Texas Department of Insurance and/or the Social Security Administration or its intermediaries, pertaining to this or any related medical claim(s). I permit copy of this authorization to be used in place of the original and request payment of medical insurance benefits to the ADVANCED FACIAL PLASTIC SURGERY CENTER for bills or service furnished to me. I also understand and acknowledge that I am personally responsible to pay ADVANCED FACIAL PLASTIC SURGERY CENTER in full for services that my health insurer will not cover due to non-payment for my health insurance premiums.
Fees for all services performed are determined by Dr. Bassichis alone. These fees are non-negotiable under any circumstance, by any party, and payment must be received at the time of service. We will not barter nor accept products or services in exchange for surgery or treatments. Should a balance appear on your account after the date of service for any reason, you will be notified and required to pay those charges within 90 days of that notice. If after 90 days payment has not been received, your account will be reviewed and sent to an outside collection agency. In the event a check is written for services rendered and does not clear your bank account, your balance will then be reinstated and a $50 bounced check fee will be added.
I have read and understand the above policies. I understand that all fees paid are non refundable unless deemed medically necessary by Dr. Bassichis. Proof of medical condition must be supplied to provide evidence of medical necessity and refund consideration.
Patient Confidentiality Policy & Treatment of Private Medical Information
We are committed to providing you with quality, personal health care. As part of our professional relationship, it is important that you understand our Patient Confidentiality Policy. Agreement with these policies is required for all medical services provided through ADVANCED FACIAL PLASTIC SURGERY CENTER.
1. Please list all family members or other personal representatives and their relation to you who may receive information about your medical condition and/or treatment (i.e. pick up RX, medical reports, financial information):
2. Please indicate where confidential health information can be left (i.e. appointment reminders, test results):
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY BEFORE SIGNING THE ACKNOWLEDGMENT. If you have any questions about this notice please contact our Corporate Compliance and Privacy Officer at 14755 Preston Rd Suite #110 Dallas, TX 75254 or at (972)774-1
Purpose of This Notice
CE This notice describes the way in which we may use and disclose medical information about you. This notice also describes your rights and certain obligations we have regarding the use and disclosure of medical information.
Our Legal Requirements
We are required by law to:
• Ensure that your protected health information that identifies you is kept private
• Give you notice of our legal duties and privacy practices with respect to medical information about you.
• Follow the terms of the notice that currently is in effect.
• Change the notice only in accordance with federal rules
• Provide our internal compliant process for privacy issues to you.
Who Will Follow Our Privacy Practices
This notice describes the practices of ADVANCED FACIAL PLASTIC SURGERY CENTER and that of
• All ADVANCED employees, staff and other ADVANCED personnel.
• ADVANCED affiliated entities and subsidiaries (all of which are collectively referred to as “ADVANCED")
All these entities, sites, and locations follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for treatment, payment, or health care operations purposes described in this notice.
I agree that I have received a copy of the privacy practice document. If I have any questions, concerns, or complaints, I will forward these to the Corporate Compliance and Privacy Officer whose contact information is located in the first paragraph of the Privacy Practices information.
** Please let us know if you need a copy of our Privacy Policies**
We are committed to excellence in patient care. Thank you for your confidence and trust.
Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold MK Periodontics & Implants, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.
By checking this box, I acknowledge my understanding of the HIPAA Policy and agree with its contents.