PLASTIC SURGERY ASSOCIATES OF NORTHERN VIRGINIA, LTD



Bruce M. Freedman MD FACS

Plastic and Reconstructive Surgery

1800 Town Center Drive ( Suite 413 ( Reston, VA 20190 ( 703-790-5700 ( FAX 703-827-8730



PLEASE PRINT Patient Registration Form Today’s Date:

Name: PHONE NUMBERS BELOW

Address: (H):

City State Zip Code (C):

Employer: (W):

Date of Birth: ____/____/_____ Age: _____ Sex: M F Marital Status: S M D W Sep

Height: ‘ “ Weight: _ Who referred you to our office?

Email:_____________________________________________________________

Where should statements of your account be sent if different from above?

Name Address City State Zip

In case of Emergency, who should be notified? Phone

Primary Care Physician Phone

Do we have your permission to:

Leave a message on your answering machine at home? YES NO

Leave a message at your place of employment? YES NO

Discuss your medical condition with any member of your household? YES NO

If yes, whom: Relationship

Signature of patient or legal guardian Date

What brings you to our office? Please be as specific as possible

How long have you had this condition?

Have you had any previous treatment for this condition?

If YES, how and when was this treated?

INSURANCE INFORMATION (Not needed for Cosmetic Patients)

Do you require a REFERRAL for this visit?

Primary Insurance Name Secondary Insurance Name

Ins. Address Ins. Address

Name of Insured Name of Insured

Insured’s ID# Insured’s ID#

Insured’s Date of Birth: Insured’s Date of Birth:

Group # Group#

Relationship of patient to the Insured Relationship of patient to the Insured

Do you have or have you had any of the following? (Please check yes or no.)

Yes No Yes No

AIDS or HIV positive ( ( Hepatitis ( (

Anemia ( ( High blood pressure ( (

Arthritis ( ( Irregular heart beat ( (

Asthma ( ( Kidney problems ( (

Back problems ( ( Migraine headaches ( (

Blood clots in legs ( ( Nervous breakdown ( (

Blood disorders ( ( Nose/throat problems ( (

Bleeding problems ( ( Pneumonia ( (

Breathing problems ( ( Psychiatric condition ( (

Cancer ( ( Rheumatic fever ( (

Chest pains ( ( Seizures ( (

Colitis ( ( Shortness of breath ( (

Diabetes ( ( Skin cancer ( (

Ear/Eye problems ( ( Stomach problems ( (

Epilepsy ( ( Stroke ( (

Cold sores / oral herpes ( ( Thyroid problems ( (

Heart murmur ( ( Tuberculosis ( (

Heart palpitations ( ( Transfusion ( (

Past, Family and/or Social History:

Current medical conditions:

List any hospitalizations and/or previous surgery (including cosmetic/plastic surgery), with dates: _______

Are you allergic to or have you ever had a reaction to any medication or drug; local anesthetic; or general Anesthetic?

Are you now or have you ever taken any medications regularly (aspirin, birth control pills, vitamins, etc.)?

Currently taking:

Previously taken:

Do you currently smoke: Yes No If yes, how many packs per day? How many years?

Notice Of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. A copy of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information is available upon request. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

Patient Name: Relationship to Patient:

Signature: Date:

Cosmetic Patients

Fees for in-office treatments such as Microdermabrasion, Botox™, fillers, chemical peels, laser treatments, and other non-surgical procedures are priced either on a per treatment basis or as a treatment package option. Prepaid packages for ancillary procedures are non-refundable. Office treatments and skin care products are payable in full at the time of your appointment. After five (5) working days there will be NO RETURNS / REFUNDS on products purchased. If patients wish to change or cancel their scheduled appointment, they need to do so at least twenty-four (24) hours prior to their appointment or a $100.00 dollar fee will be imposed.

The fees quoted for cosmetic surgery are inclusive of the following: your pre-operative examination, surgical costs, anesthesia, most supplies, and your post-operative visits. In order to schedule a cosmetic surgical procedure a $500.00 deposit is required. THIS FEE IS NON-REFUNDABLE and will not be returned once surgical time is reserved. All surgical fees must be paid at or prior to the pre-operative visit. The pre-operative visit is scheduled approximately 10 to 14 days prior to the surgery date. All surgical fees are payable in the form of Cash, Master Card, Visa, American Express, Discover or Certified Check. The reservation fee will be deducted from the balance due. All financing arrangements must be approved prior to the pre-operative appointment. Any surgery cancelled after the pre-operative appointment for the surgery will be subject to a 100% cancellation fee. Notification must be made by the patient or their authorized agent verbally or in writing. Voice messages cannot be accepted. A $32.00 service charge will be added to your account for each check returned to our office due to insufficient funds. If at any time these fees change at our financial institution you are responsible for the current fees for returned checks.

Please complete financial arrangements at least two weeks prior to your surgery date. Patients interested in our financing options should speak with the staff before making surgical arrangements.

Statement of Financial Responsibility

I, the undersigned, have read the above and realize that all medical and surgical charges incurred by me or my dependents for services rendered by Plastic Surgery Associates of Northern Virginia, Ltd., are my financial responsibility. There will be a $25.00 charge for Insurance / Disability forms that need to be completed by a physician. All court fees or other fees necessary to collect this account are payable by me.

Signature of insured or responsible party: Date:

Insurance Billing Policy

Insurance Patients

This office participates with several insurance companies and their various types of plans. We do not take every plan of any given insurance company. It is your responsibility to find out, in advance, what your particular plan covers and if the doctors are participating providers in your plan. If we are not participating providers in your network, then you are responsible for your bill in its entirety and we will provide you the necessary paperwork and assist you with filing your insurance claim so that you may be reimbursed from your insurance company directly.

Some insurance plans require that a primary-care doctor approve an office visit to a specialist. If there is no preauthorization, the insurance company will not pay for the visit. Please avoid this problem by confirming preauthorization for visit. Please refer to the back of your card for a contact phone number to get additional

Financial Policies continued

information. If we may be of assistance, please contact us. However, it remains your financial responsibility for complete payment if you are seen and/or treated and your insurance company declines payment.

If your insurance company has not paid their portion within 90 days, you are responsible for full payment at that time. Account balances unpaid beyond 90 days from the date of service are subject to a Finance Charge of 1.5% (18% annually) on the current balance due, unless other financial arrangements have been authorized. You have agreed to be responsible for all costs of collections including court costs and attorney’s fees in the amount of 33.33% of the outstanding balance. A $32.00 service charge will be added to your account for each check returned to our office due to insufficient funds. If at any time these fees change at our financial institution you are responsible for the current fees for returned checks.

Insurance Benefits

Office co-payments are due by the subscriber at the time of the visit. We will submit all claims directly to the insurance company. Some insurance companies pay 100% of the surgical fee, others pay only a percentage. You will be responsible for any co-payments or deductibles under your insurance plan regardless of the type of benefits you have

Assignment of Benefits

I, the undersigned, hereby authorize payment of medical and surgical benefits for services rendered directly to Plastic Surgery Associates of Northern Virginia, Ltd.

I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all my insurance submissions.

Signature of insured or responsible party: Date:

Medicare and Medigap Participants

I request that payment of authorized benefits, if applicable, be made on my behalf to Plastic Surgery Associates of Northern Virginia, Ltd., for services rendered. I understand my signature requests that payment be made and authorizes the release of medical information necessary to pay the claim. If ‘other insurance’ is indicated in item 9 of the HCFA-1500 form or elsewhere on the other approved claim forms of electronically submitted claims, my signature authorizes the releasing of information to the insurer or agency shown. I understand that the deductible, coinsurance and non-covered services will be my responsibility.

Signature of insured or responsible party: Date:

Workman’s Compensation

The workman’s compensation system requires that you and/or your employer provide the office with your claim number and all necessary information for the office to process your claim. This will avoid any problems with your care delivery and claim processing. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of my signature on all my insurance submissions.

Signature of insured or responsible party: Date:

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