New-Patient Form

Patient Information

Communication Agreement

Patient Health History

Have you had any of the following?

Patient Health History

Insurance Information (If Applicable)

The patient requesting care is responsible for payment. Co-payments and deductibles are due at the time of service.

I hereby authorize release of information necessary to file a claim with my insurance company and assign benefits otherwise payable to me to the doctor or the corporation as indicated on the claim. A copy of my signature is as valid as the original. I certify that all of the demographic, medical, and insurance information is complete and correct.

Notice of Privacy Practices

To our patients – This notice describes how health information about you, as a patient of this practice, may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.

We realize that these laws are complicated, but we must provide you with the following important information:

The following circumstances may require us to use or disclose your health information:

• To public health authorities and health oversight agencies that are authorized by law to collect information.
• Lawsuits and similar proceedings in response to a court or administrative order.
• If required to do so by a law enforcement official.
• When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
• If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
• To federal officials for intelligence and national security activities authorized by law.
• To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.
• For Workers Compensation and similar programs.

1. Communications. You can request that our practice communicates with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for you care, such as family member and friends. We are not required to agree to your request, however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Administrator–Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960 for further information. A meeting will be schedule with the Administrator to inspect your records after we receive your request.

4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Administrator – Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823. You must provide us with a reason that supports your request for amendment.

5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy of this notice, contact Administrator – Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960.

6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Administrator – Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact Administrator – Dr. Lee H. Colony, 2900 Hannah Boulevard, Suite 110, East Lansing, Michigan 48823 or by telephone 517-333-4960.

I hereby acknowledge that I have been presented with a copy of Dr. Lee H. Colony – Michigan Plastic Surgery – Notice of Privacy Practice

Notice of Privacy Practices

October, 2002

Patient Financial Policy

• In order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the followingfinancial policy. If you have any questions about the policy, please discuss them with our practice administrator. We are dedicated to providing the best possible care and service to you and regard your complete understanding of yourfinancial responsibilities as an essential element of your care and treatment.
• Unless other arrangements have been made in advance by either yourself or your health coverage carrier, full payment for cosmetic procedures is due ten (10) days prior to your procedure. For your convenience we will accept VISA/Discover/Mastercard and American Express.
• Your insurance policy is a contract between you and your insurance company, the doctor is not involved.
• As a courtesy, we will file your insurance claim for you if you assign the benefits to the doctor. In other words, you agree to have your insurance pay the doctor directly. If your insurance company does not pay the practice within a reasonable length of time, we will have to look to you for payment.
• We have made prior arrangements with many insurers and other health plans to accept an assignment of benefits. Wewill bill those plans for whom we have an agreement and will only require you to pay the authorized co-payment at thetime of service. We will collect the co-payment when you are here for your appointment.
• If you have insurance coverage with a plan that we do not have a prior agreement, we will prepare and send the claimfor you on an unassigned basis. This means your insurer will send the payment directly to you. Therefore, our chargesfor your care and treatment are due at the time of the service.
• All health plans are not the same and do not cover the same services. In the event your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
• It is the patient’s responsibility to contact their insurance carrier and to know if the doctor is in-network or out of network according to their plan.
• For all services provided in the hospital, we will bill your health plan. Any balance due is your responsibility and is dueupon receipt of a statement from our office.
• For all services rendered to minor patients, we will look to the adult accompanying the patient and the parent orguardian with custody for payment.
• In order to provide the best possible service and availability to all our patients, please call us as early as possible if youknow you will need to reschedule your appointment.
• I have read and understand the financial policy of the practice and I agree to be bound by its terms. I also understandand agree that such terms may be amended from time-to-time by the practice.

Informed Consent for Telemedicine Services

INTRODUCTION:

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical/dental information for the purpose of improving patient care. Providers may include primary care clinicians, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient healthcare records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

EXPECTED BENEFITS:

• Improved access to medical care by enabling a patient to remain at a remote site.
• More efficient healthcare evaluation and management.
• Obtaining expertise of a distant specialist.

POSSIBLE RISKS:

As with any healthcare procedure, there are potential risks associated with the use of telemedicine. The risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant (s).
• Delays in evaluation and treatment could occur due to deficiencies or failures of the equipment.
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
• In rare cases, a lack of access to complete treatment may result in adverse drug interactions or allergic reactions or other judgment errors.

BY SIGNING THIS FORM, I UNDERSTAND THE FOLLOWING:

1. I understand the laws that protect privacy and the confidentiality of healthcare information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.

2. I understand I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and my receive copies of this information for a reasonable fee.

4. I understand a variety of alternative methods of healthcare may be available to me, and that I may choose one or more of these at any time. My clinician has explained the alternatives to my satisfaction.

5. I understand telemedicine may involve electronic communication of my personal healthcare information to other healthcare practitioners who may be located in other areas, including out of state.

6. I understand it is my duty to inform my clinician of electronic interactions regarding my care that I may have with other healthcare providers.

7. I understand I may expect the anticipated benefits from the use of telemedicine in my care, but no results can be guaranteed or assured.

PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understand the information provided above regarding telemedicine, have discussed it with my clinician as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my healthcare.

I hereby authorize LEE H. COLONY, MD, PC to use telemedicine in the course of my diagnosis and treatment.