In case of an emergency I authorize Provider to contact:
Please skip if you are paying for the service or if you are bringing your insurance card with you
Primary Insurance Information
Secondary Insurance Information
I wish to be contacted by Provider in the following manner (please check all areas that would be an acceptable manner for Provider to contact you):
From time to time our practice holds educational seminars, announces new procedures & products to enhance the quality of life for our patients, and have programs to make services more affordable. By filling in your information below you will be notified. This information will only be used by our office for your benefit & never released to another entity.
By signing this authorization form, I understand that:
list which family member next to affected disorder
Please make a mark next to any of the following persistent symptoms you have had in the past few months. Read through every section and check “No Problems” if none of the symptoms apply to you. If you have symptoms that are not listed, please list them on the space provided below.
The above information is complete and correct to the best of my knowledge. I consent to consult with Dr. Johnston for his recommendations of treatment and/or surgical opinion for which I made this consultation. In addition, I consent to any photographs which may be taken and permit their use strictly for medical, educational and scientific purposes. Photographs will be property of Dean L. Johnston, M.D.
I, the undersigned, certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Dean L. Johnston, M.D., Inc. all insurance benefits payable to me for services rendered. I understand that I am responsible for co-pays, deductibles, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize Release of Medical Information to my insurance carrier, or requested physician to provide continuity of care. I authorize any physician or medical facility that has treated me in the past to release a copy of my record to Dean L. Johnston, M.D., Inc. I authorize use of this signature on all insurance benefits.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.
As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your protected health information (PHI) and who we may use and disclose your PHI for treatment, payment, health care operations (TPO), and for other purposes that are permitted or required by law.
We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may contact you to provide appointment reminders or health information about treatment alternatives or other health related benefits and services that may be of interest to you.
We may release some or all of your health information when required by law.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, which we are required to honor and abide by, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: Dean L. Johnston M.D. FACS, 4106 W. LAKE MARY BLVD. SUITE 212, LAKE MARY, FL 32746 (407) 333-2525.
We are required by law to maintain the privacy of your protected health information, and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
We are required to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices and to make new provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
If you feel that your privacy protections have been violated, you have the write to file a written complaint with our office. You may also file complaints with the Department of Health and Human Services or Office of Civil Rights about violations of the provisions of this notice, or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
For more information: The U.S. Department of Health and Human Services/Office of Civil Rights
200 Independence Avenue, S.W. Washington, D.C., 20201
(202) 619-0257 Toll Free: (877) 696-8775
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby give my consent for Orlando Plastic Surgery Associates to use and disclose protected health information (PHI) about me to carry out treatment, payment, and healthcare operations (TPO). All matters concerning my medical care will be considered to be a health care treatment, and subject to the Medical Practices Act. (Orlando Plastic Surgery Associates Notice of Privacy Practices provides a more complete description of such uses and disclosures.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Orlando Plastic Surgery Associates reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Orlando Plastic Surgery Associates acting privacy officer, Kathy Johnston, R.N., at 4106 West Lake Mary Blvd., Suite 212, Lake Mary, FL 32746. With this consent, Orlando Plastic Surgery Associates may call my home or other alternative location and leave a message on a voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items, and any calls pertaining to my clinical care, including laboratory results among others.
With this consent, Orlando Plastic Surgery Associates may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements, as long as they are marked Personal and Confidential. With this consent, Orlando Plastic Surgery Associates may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminders and patient statements. I have the right to request that Orlando Plastic Surgery Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By signing this form, I am consenting to Orlando Plastic Surgery Associates use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Orlando Plastic Surgery Associates may decline to provide treatment to me.
Thank you for choosing Dean L. Johnston, M.D., Inc. as your health care provider. We are committed to the success of your treatment. All matters concerning your medical care will be considered to be a health care treatment and subject to the Medical Practices Act of Florida. The medical services provided by our office are services you have elected to receive, which imply a financial responsibility on your part.
Cosmetic Procedures/Self PayElective procedures must have financial arrangements made in advance of scheduling. Payment for services is due two weeks prior to the procedure. The practice will accept cash, carrier’s checks, personal checks, and the following major credit cards: VISA, MasterCard, and American Express. We charge a $25 service fee for all returned checks. As a convenience to you, financing is also available. For those individuals who pay by credit card, debit card, or finance companies, you are not eligible for credit card challenge or “charge back” to the finance companies once the service is provided as per this agreement.
InsuranceWe participate in most insurance plans. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date card, payment in full for each visit is required until we can verify coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage plan.
MedicareWe are a participating Medicare provider. Medicare as well as your secondary insurance (if any) will be billed for you. However, that does not mean that all services are covered. Patients are responsible for paying their annual deductible if it has not been met. You are also responsible for any co-payments, which are usually 20% of the allowed amount for an item or service.
Co-payments and DeductiblesAll co-payments and deductibles must be paid in full at the time of service. This arrangement is part of your contract with your insurance company.
Self PayPayment in full is due at the time of service if you do not have health insurance.
Non-Covered ServicesPlease be aware that some services you receive may not be covered, or considered reasonable or medically necessary for coverage by Medicare or other insurance carriers. You are responsible for payment of these services.
Referrals/AuthorizationsWe are required to follow the guidelines of your managed care plan, which may require a referral from your primary care physician prior to your appointment when visiting a specialist’s office. Therefore, if a referral is required and not presented at the time of your visit, your appointment will be rescheduled or you will be financially responsible for services received, paid in full upon completion of the visit.
Claim SubmissionAs a courtesy service to you, we will submit your insurance claims for the services rendered in our office, and assist you in anyway we reasonably can to help get your claims paid. Your insurance company may need information from you. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility, whether or not your insurance company pays your claim.
Patient BillingYou will receive a statement from us on the status of your claim and encourage your help in receiving payment after 30 days. You will be sent up to three statements for your financial responsibility after your insurance has processed Claims. After the third notice your account may be forwarded to a Collection Agency. If your account is assigned to an outside collection agency, additional fees will be added. Please let the billing departments know if you have difficulties resolving your bill. Payment arrangements may be considered on a case-to-case basis.
Form CompletionCompleting Disability Forms, Family Leave Forms, or your third insurance forms require office staff time, copies to be made, and time out of Dr. Johnston’s schedule which takes away from patient care. Therefore, our charge for this service is $15.00 and we request up to three business days for completion of this task.
Payment PolicyAll balances will be due in full at the time of your office visit. We will provide you with a copy of your bill and the insurance credits upon request. We reserve the right to charge a $50.00 fee for missed appointments and an additional charge for surgical appointments. If you are unable to make your appointment, please cancel or reschedule by calling our office at least 24 hours in advance.
If I am paying by insurance, I the undersigned certify that I (or my dependent) have coverage with my insurance as presented and assign directly to Dean L. Johnston, M.D., Inc. all insurance benefits payable to me for services rendered. I understand that I am responsible for co-pays, deductibles, and/or non-covered services. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize Release of Medical Information to my insurance carrier, or requested physician to provide continuity of care. I authorize any physician or medical facility that has treated me in the past to release a copy of my record to Dean L. Johnston, M.D., Inc. I authorize use of this signature on all insurance benefits.
I understand that it is my responsibility to inform the Doctor’s office if there is a change in my health insurance information and/or contact information. I understand and accept these terms.
Call: 321-247-7647 Email: firstname.lastname@example.org