This form will be provided for your signature at your first office visit.
I Hereby Consent to the Following:
I authorize The Plastic Surgery Group, LLP to release all medical records pertaining to medical history, services rendered or treatment for me or my dependents for insurance claims.
I authorize payment of medical benefits to The Plastic Surgery Group, LLP.
I promise as guarantor for the above patient or as the patient, to pay for medical services at the time of service, unless prior arrangements have been made.
I understand that I am financially responsible for all charges incurred, whether or not they are covered/paid by my insurances.
Permission for Taking Photographs
I hereby consent that photographs may be taken of me or the named patient by The Plastic Surgery Group, LLP in connection with the medical care and treatment received.
I give / do not give (circle one) permission for my photographs to be used for educational purposes.
Consent to Release and HIPAA Acknowledgement
I hereby authorize The Plastic Surgery Group, LLP to discuss my medical and payment information with: