Albany, New York: (518) 650-1076

Patient Information Form

Fields marked with * are required.

Patient Information

First Name: *
Initial:
Last Name: *
Suffix:
Email Address: *
Address: *
City/State: *
Zip Code: *
Sex: * Male    Female
Employed: * Yes    No
Employer:
Work Telephone:
Home Telephone: *
Cell Telephone:
Date of Birth: *
Social Security:
Marital Status: *
Primary Care Physician: *
Phone: *
Referring Physician:
Phone:
Referral Sources: * Times Union   Spotlight
Other Newspaper   Radio   TV
Seminar   Family/Friend
Yellow Pages   Website   Physician
Other (Please explain)
Contact in case of emergency: *
Relationship: *
Phone: *
Email address: *

Responsible Party Information (Insurance Subscriber)

Is the patient also the Insurance Subscriber? * Yes No (If No, please complete this section.)
Last Name:
First Name & Initial:
Address:
City/State:
Zip Code:
Employed: Yes No
Employer:
Work Telephone:
Home Telephone:
Date of Birth:
Social Security:
Marital Status:
Relationship to patient:

Insurance Information

Primary Insurance: *
Subscriber Number: *
Group Number: *
Copay: *
Secondary Insurance:
Subscriber Number:
Group Number:
Copay:

Injury Information

Is injury work related? * Yes No (If yes, please complete this section)
Date of injury:
Employer:
Address:
Phone:
Employer's Insurance Co.:
Address:
Phone:
Is injury related to a car accident? * Yes No (If yes, please complete this section)
Date of injury:
Auto Insurance Subscriber:
Phone:
Auto Insurance Co.:
Phone:
Address:

This form will be provided for your signature at your first office visit.

I Hereby Consent to the Following:

Authorization

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:

1.
Relationship
2.
Relationship
3.
Relationship
I acknowledge that I have received a copy of The Plastic Surgery Group, LLP's notice of Privacy Practices. This notice describes how The Plastic Surgery Group, LLP may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
Patient / Guardian:
FOR OFFICE USE ONLY
Date:
FOR OFFICE USE ONLY
Would you like to receive our electronic newsletter? * Yes
* Periodically we distribute the latest information on cosmetic surgery procedures, skin care products and services, and special savings offers. Your email address will never be shared or sold.