**ALL PATIENTS - Please complete the applicable sections for your treatment.
Please complete the following:ASSIGNMENT OF INSURANCE BENEFITSI hereby authorize and instruct my insurance carrier to make payment directly to American Institute for Plastic Surgery (AIPS) and/or the Surgery Center of Texas for charges incurred. I further assign all rights to the payment due for medical and/or surgical services under-listed policies to AIPS Surgery Center of Texas, Anesthesia, Pathology, and Radiology providers. I understand that any payment made on my behalf is not refundable to me.
Please complete the following:CONSENT FOR IRREVOCABLE NON-ASSIGNMENT: I understand the procedure(s) I seek are cosmetic, not medically necessary and it would be fraudulent and unethical for AIPS and/or Surgery Center of Texas to submit a charge to any insurance company for payment. Therefore, I understand that AIPS and/or Surgery Center of Texas will not accept insurance for my procedure(s). My consent to having AIPS and/or Surgery Center of Texas provides care and not accept assignment from any insurance company, managed care provider or another coverage source is irrevocable and final. I understand I will be fully responsible for surgical fees for the surgery I seek.
Please complete the following:INFORMED CONSENT-PATIENT COMPUTER IMAGING: In the course of the consultation, I may have been shown brochures or photographs of actual patients on a computer screen. I understand that those pictures and any alterations of these pictures are solely for the purpose of illustration. Furthermore, I understand that the outcome of any type of surgical procedure is related to my individual characteristics and health. I understand that because of the differences in how living tissues react to surgery, there may be no relationship between the electronic images created and my actual final surgical result. The use of a computer imaging system offers an opportunity for me to discuss my desires and allows for improved communication with the medical staff.
RELEASE OF PHOTOGRAPHIC IMAGES: I hereby grant permission for the use of any illustrations, photographs, or imaging records, created in my case, for use in scientific and professional journals, the AIPS website, or other medical or patient education material and presentations at any time during or after treatment, with complete confidentiality of my identity.
CONSENT/RESTRICTION OF THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS: I understand that as part of my healthcare, this practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans of future care or treatment. I understand that this information serves as a basis for planning my care and treatment, a means of communication among the healthcare professionals who contribute to my care, a source of information for applying my diagnosis and surgical information to my bill, a means by which a third-party payer can verify that services billed were actually provided, and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals. I wish to have the following restrictions to use or disclosure of my health information.
Signature of Patient or GuardianPatient, if minor (Parent or Guardian Signature)
One fine body…