O’BRIEN PLASTIC SURGERY
Cosmetic & Reconstructive Surgery
PATIENT INFORMATION
LAST NAME___________________________________________FIRST____________________________MI_________ AGE___________
ADDRESS_________________________________________________________________________ BIRTH DATE____________________
CITY, STATE, ZIP___________________________________________________________________HOME PHONE__________________
EMPLOYER_________________________________________WORK PHONE_________________CELL PHONE___________________
SEX__________MARITAL STATUS_______________________________SOCIAL SECURITY #_________________________________
CONSULTATION REQUESTED BY OR REFERRED BY:________________________________________________________________
PRIMARY INSURANCE:
NAME______________________________________________________ADDRESS OF COMPANY_______________________________
CONTRACT#_________________________________GROUP #________________POLICY HOLDER BIRTH DATE________________
POLICYHOLDER____________________________________________________________RELATIONSHIP________________________
Thank you for selecting the practice of Kevin O’Brien, M.D. (“the Practice”) for your plastic and aesthetic surgery needs. In order to confirm your treatment and
payment responsibilities for services provided to you, we have developed this “Conditions for Treatment and Payment” form.
Please read the following information carefully and sign below.
A. Consent to Treatment:
I consent to the provision of treatment and care by Kevin O’Brien, M.D. and health care personnel authorized to assist him. I understand that Dr. O’Brien
performs plastic and aesthetic surgery/services at his Practice and that my treatment will generally require Dr. O’Brien to employ assistance from authorized
Practice personnel. Should I fail to understand the purpose or risks associated with the treatment and procedures performed, I will request an explanation or
clarification to my satisfaction.
As part of my treatment, I understand that medical photographs, digital images or other representations may be recorded to document my care and I consent
to these images being taken. Images that identify me will be stored in a secure manner that will protect my privacy and will not be released and/or used for
purposes other than treatment, payment, and/or health care operations without written authorization from me or my authorized legal representative(s).
B. Consent to Payment:
As a condition of my treatment by Dr. O’Brien, I understand that payment is expected at the time services are rendered. I am responsible for the total charges
for the care and treatment provided by Dr. O’Brien, including costs not covered by my insurance company, Medicare or other health care benefits programs.
This balance shall include any applicable deductibles, co-pays or costs of items or services not covered as part of my insurance or benefits programs.
In cases where insurance or other health benefits programs cover the cost of my treatment and care, the Practice will bill my insurance company or benefits
program as a courtesy to me (the patient) and will accept assignment of benefits. However, the Practice asks that I ;assist in helping obtain the necessary
authorizations, insurance/benefits card copies, referral numbers, and other critical documents in order to smoothly expedite my care and reimbursement for
services rendered. I understand that failure by me to provide requested documentation and information necessary to process my health care claims may
(and will) require payment from me at the time of service.
In the event treatment and services are not covered by my insurance company or health benefits program, or where my insurer is not an approved payor, I or
the undersigned guarantor (the individual who is responsible for payment on the account) shall be responsible for the full outstanding balance, including any
late fees. The assignment of insurance will not relieve me or the guarantor from any financial obligations to the Practice. In the event my account is placed
with a collection agency or attorney upon default of payment, I or the undersigned guarantor agrees to pay all collections costs including, but not limited to
any late fees, attorney fees and court costs.
By signing below, I have read and agree to the conditions regarding consent to treatment and consent to payment.
X__________________________________________________________________________________
______________________________________
Signature of Patient or Patients Representative
Date
X________________________________________________________________________________________________________
Printed Name of Patient’s Representative & Relationship to Patient (if applicable)
This section is to be completed if a guarantor, i.e. a person other than the patient or his/her authorized representative, is responsible for payment on the account.
By signing below, I have read and agree to the conditions regarding consent to payment for services and treatment rendered.
X________________________________________________________________________________
Signature of Guarantor
________________________________________
Date
Printed Name of Guarantor & Relationship to Patient (if applicable) X___________________________________________________________________________________