Patient intake

  • Office Use Only: H&P3/12

  • Form for Patient to Fill-Out

  • IF ADDITIONAL SPACE IS NEEDED IN ANY SECTION OF THIS FORM ATTACH A SEPARATE SHEET.

  • Social History

  • Do you currently have, or have you ever had problems with:

  • PRESCRIPTION REFILL POLICY

  • Request for Prescription Medications need to be called in to our office between 8:30 a.m. and 4:00 p.m. Mondaythrough Friday. All approved prescriptions, except narcotics, will be called into the pharmacy by the end of that businessday. Narcotic prescriptions cannot be phoned in and must be picked up in the office. Prescriptions should be taken "AS DIRECTED". Early refills may be denied. NO medications will be refilled after hours, or on weekends.

    I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form.

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  • Patient Signature I have reviewed the above information with the patient.

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  • The Plastic Surgery Group & Hayes Hand Center

    D. Marshall Jemison, MD, Mark A. Brzezienski, MD Jason P. Rehm, MD Jimmy L. Waldrop, MD Todd E. Thurston, MD, Brittney S. Murphy, FNP-c
  • Patient Information Form

  • DISCLOSURE OF PROTECTED HEALTH INFORMATION

  • According to office policy, test results or release of medical information including but not limited to, appointment times, lab or test results, etc. will be provided to the patient only. Please specify below whom information may be released to other than yourself. I grant permission for The Plastic Surgery Group, PC to release any and all of my medical information to the person(s) listed below.

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  • TPSG Communicates PHI to you through secure email. However, unless you have secure email on your media device, communications from you are over public wire. There should be no assumption of confidentiality when using email over public networks.

  • The Plastic Surgery Group & Hayes Hand Center

    D. Marshall Jemison, MD, Mark A. Brzezienski, MD Jason P. Rehm, MD Jimmy L. Waldrop, MD Todd E. Thurston, MD, Brittney S. Murphy, FNP-c
  • Patient Information Form

  • FINANCIAL INFORMATION

  • IF THE PATIENT IS A MINOR / STUDENT

  • PLEASE PRESENT YOUR CURRENT INSURANCE CARD(S) TO OUR FRONT DESK

  • COMPLETE THIS SECTION IF YOU ARE COVERED UNDER MEDICARE

    Medicare law requires that we determine if your medical services might be covered by another insurer. In order to assist us in the correct billing of these services, please answer the following questions.
  • Please list employer information on front of form.

  • Please complete health plan information above.

  • Please list employer information on front of form.

  • Please complete health plan information above.

  • PLEASE COMPLETE THIS SECTION IF APPLICABLE

  • If yes, please complete the following:

  • ADVANCED DIRECTIVES

  • Please provide The Plastic Surgery Group, P.C. with a copy for your file. The Plastic Surgery Group, P.C. does not honor Advanced Directives/Living Wills and our policy is as follows. Regardless of any advanced directive if an adverse event occurs during your treatment at this office, we will initiate resuscitative or other stabilizing measures and transfer you to the nearest hospital for further evaluation. At the hospital, further treatment or withdrawal of treatment measures already begun will be ordered in accordance with your wishes, Advance Directive, or Health Care Power of Attorney. Your agreement with this policy by your signature does not revoke or invalidate any current health care power of attorney.

  • The Plastic Surgery Group & Hayes Hand Center

    D. Marshall Jemison, MD, Mark A. Brzezienski, MD Jason P. Rehm, MD Jimmy L. Waldrop, MD Todd E. Thurston, MD, Brittney S. Murphy, FNP-c
  • PATIENT CONSENT AND ASSIGNMENT FORM

  • I. CONSENT TO TREAT

    I authorize The Plastic Surgery Group, PC and Hayes Hand Center which is a division of The Plastic Surgery Group, its health care practitioners, staff, office surgery facility and other individuals involved in my care to examine me and perform any tests, procedures and/or treatments that may be helpful to care for my injury or illness.

    I understand that The Plastic Surgery Group, PC and Hayes Hand Center is dedicated to teaching, that authorized resident physicians my observe and assist in diagnosis, treatment and care, and that photographs may be taken for purposes of diagnosis, teaching and documentation. I reserve the right to give specific permission for publication of any picture that personally identifies me.

    II. PAYMENT AND FINANCIAL OBLIGATIONS

    I request that payment of authorized Medicare and/or other insurance company benefits be made to The Plastic Surgery Group, PC / Hayes Hand Center for any services furnished to me my that physician/supplien I authorize any holder of medical information about me to release to Medicare and/or other insurance companies and its agents any information needed to determine benefits of the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. In Medicare and/or other insurance company assigned cases, the physician or supplier agrees to accept the charge determined of the Medicare and/or other insurance company as the full charge, and the patient is responsible only for the deductible, coinsurance and non-covered insurance services. Coinsurance and the deductible are based upon the charge determination of the Medicare and/or other insurance company.

    I understand that I am responsible for paying all charges associated with this treatment. If I have health insurance, I understand thatI am financially responsible in the event that all or some payment is denied by my insurance carrier or other third party who is responsible for payment. I am also responsible for those charges not covered by my insurance such as deductibles, co- paysor evaluation or treatment that are not included as an insurance benefit. I understand that if my insurance plan requires a referral,prior authorization for surgery and/or a second surgical opinion and this has not been obtained, I am responsible for payment of services rendered.

    I authorize my health insurance carrier(s) or other third parties who are responsible for paying for my health care to pay costs associated with my evaluation and care directly to The Plastic Surgery Group, PC / Hayes Hand Center.

    I authorize the release of any medical information necessary to process this claim. I realize that in the event these claims are denied I am responsible for payment. I authorize my private health insurance carrier to reimburse The Plastic Surgery Group, PC / Hayes Hand Center in the event that Workers' Compensation denies payment. My carrier's failure to pay does not release me from this responsibility. I also agree that should this account be turned to collection, I will be responsible for all costs associated with debt collection, including attorney fees and court costs.

    III. CONSENT TO USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

    I consent to The Plastic Surgery Group. PC / Hayes Hand Center, its health care practitioners, staff and other individuals, use and disclosure of my protected health information ("PHI") in support of my diagnosis and treatment, payment for themedical services I receive, and the legitimate health care operations of the medical practice. I consent to The Plastic Surgery Group, PC / Hayes Hand Center disclosure of PHI to other health care practitioners and facilities that are involved in providing medical services to me.

  • Also, I consent to The Plastic Surgery Group, PC / Hayes Hand Center disclosure of PHI to my health insurance carrier, utilization review organization, or third-party administrator to support payment for my medical services.

    I understand that The Plastic Surgery Group, PC / Hayes Hand Center's agreement to provide medical services to me is conditioned upon my signing of this consent and that The Plastic Surgery Group, PC / Hayes Hand Center requests my consent to ensure that The Plastic Surgery Group, PC / Hayes Hand Center can properly carry out the professional responsibility of caring for me.

    I understand that The Plastic Surgery Group, PC / Hayes Hand Center will disclose only the minimum of my health care information that is necessary, in the judgement of The Plastic Surgery Group, PC / Hayes Hand Center for the legitimate needs of the recipient or for my general wellbeing.

    My PHI which is the subject of this consent includes demographic information, information about my physical or mental health or condition, information about the medical services provided to me (including payment information) if any of that information may be used to identify me. (Depending upon the medical services I request or require this information may includeinformation about treatment for HIV/AIDS, sexually-transmitted diseases, mental health or psychiatric conditions, or substance abuse

    I understand that I have a right to restrict The Plastic Surgery Group, PC / Hayes Hand Center's use and disclosure of my PHI and that The Plastic Surgery Group, PC / Hayes Hand Center is not obligated to agree to the requested restriction, but that an agreement to a restriction binds The Plastic Surgery Group, PC / Hayes Hand Center. I may revoke this consent at any time by providing The Plastic Surgery Group, PC / Hayes Hand Center with a written, signed and dated request except to the extent that The Plastic Surgery Group, PC / Hayes Hand Center has acted in reliance upon my consent, However, I understand that any restriction on the use and disclosure of PHI or revocation of this consent may result in improper diagnosis or treatment, denial or coverage of a claim for insurance benefits, or other adverse consequences.

    I acknowledge that this consent will remain in effect for al subsequent uses and disclosures for the limited purposes above for 30 months from the date of this consent unless I revoke it earlier as described above.

    I have received a copy of The Plastic Surgery Group, PC / Hayes Hand Center's Notice of Privacy Practicesthatprovidea morecomplete description of the uses and disclosures addressed above and l have had an opportunity to review the Notice of Privacy Practices before signing this consent. I acknowledge that the Plastic Surgery Group, PC / Hayes Hand Center reserve the right to amend the Notice of Privacy Practices periodically. I understand that I may obtain a current copy of the Notice by contacting the office staff at any time.

  • I understand that if I have any questions about this consent or about The Plastic Surgery Group, PC / Hayes Hand Center's privacy practices, or if I wish to have a copy of this consent, I may ask the office staff or my physician.

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CALL PLASTIC SURGERY             423.756.7134
CALL SPA                                       423.541.6464

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