Surgery Deposit Form

(2022) Surgery Deposit Form

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

We want to help our patients fully understand their financial obligations when scheduling surgery at our practice, along with our payment and cancellation policies prior to undergoing surgery with Dr. Becker. When you schedule your surgery, we must secure a time in the operating room at the surgery center as well as with our Anesthesia group. Both the facility and our Anesthesia group hold Dr. Becker accountable if this time is not used. Furthermore, we must turn down every other patient who wants surgery on the day and time we have reserved on your behalf. The Surgical Deposit & Payment Policy Agreement is outlined below. When you feel you understand the contents of this form and agree to the terms, please sign and date on the line indicated below.

I understand that once my surgery is scheduled with Dr. Becker and the operating room is reserved at a specific time for me, it is no longer available to other patients. Therefore, I agree to submit a $1000 surgical deposit at the time I request my surgery to be scheduled. The operating room and anesthesia fees are all included in your total cost to Dr. Becker. Pathology testing (if requested) is a bill that is not included in surgery cost. Any remaining balance for your surgery must be paid in full on the Monday, three weeks prior to the date of your surgery, which can be split into a maximum of two (2) separate card transactions that day.

Cancellation and Rescheduling Policy:

Cancellation ANY TIME up to 45 days prior to surgery date – 50% Refund of $1000 Deposit.
Cancellation at 45 days or less prior to surgery date – 100% Forfeiture of $1000 Deposit.
Cancellation, once PAID IN FULL, at three weeks (21 days) or less prior to surgery date – 100% Forfeiture of Surgery cost.

There will be no funds held back in the event of rescheduling or cancellation by our office.

I understand that I, as a patient, am responsible for any and all costs assigned to me and my surgery, and fully agree to all deposit and payment terms listed above.

Print Name

Date

Signature

Clear

If you are human, leave this field blank.

Patient Responsibility Form

(2022) Patient Responsibility Form

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

PATIENT RESPONSIBILITY FORM

INDIVIDUAL’S FINANCIAL RESPONSIBILITY

- I understand that I’m financially responsible for my health insurance deductible, co insurance or non-covered service.
- Co-payments are due at the time of service.
- If my plan requires a referral, I must obtain it prior to my visit.
- In the event that my health plan determines a service to be “not payable” I will be responsible for the complete charge and agree to pay for the medical services rendered to me at the time of service.
- If I am uninsured, I agree to pay for the medical services rendered to me at the time of service.

INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFIT
I hereby authorize and direct payment of my medical benefits to Dr. Bradley Becker, D.O., on my behalf for any services furnished to me by the providers.

AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Dr. Bradley Becker, D.O., to release to my insurer, government agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.

MEDICARE REQUEST FOR PAYMENT
I request payment of authorization Medicare benefits to me or on my behalf for any services furnished to me by Dr. Bradley Becker, D.O. I authorize any holder of medical or other information about me to release to Medicare and its agents any information needed to determine these benefits or benefits for related services.

OUT OF POCKET PROCEDURES
I understand that my procedure is strictly out of pocket cost and that at no time will my procedure be submitted by Dr. Becker to insurance for payment. Furthermore, our office will not be providing any assistance for insurance claims. This includes but is not limited to codes, authorizations, itemized billing, etc.

Signature

Clear

Date

Print Name of Patient/Authorized Representative

Relationship to Patient

If you are human, leave this field blank.

Implant Disposal Form

Please select a valid form

Implant Removal Form

(2022) Implant Removal Form

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

IMPLANT REMOVAL AND DISPOSAL FORM

Date

I,

DOB:

consent to the removal of my implants.

The reason for this procedure is:

and will be performed by Bradley Becker, D.0., P.L.L.C. and his designated assistant(s).

I understand that after removing the implants, they are cleaned but not sterilized.

I understand that no matter what kind of material the implant is made of or where it existed inside the body, all implants, once extracted, are treated as medical waste and are considered a biological hazard. They contain blood or other bodily fluids and matter, they must never be disposed of with municipal trash.

I understand, I am solely responsible for the disposal of the implants in safe way.

I understand that Dr. Bradley Becker and/or Surgical Center are no longer liable for these implants after removal.

Signature

Clear

Date

If you are human, leave this field blank.

Medical History Form

(2022) Medical History Form

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

MEDICAL HISTORY FORM

Date

Name:

DOB:

Age:

Sex

Male

Female

Height:

Weight:

How did you hear about us? Magazine add, Instagram etc.

History: CC

BREAST:

Last Mammogram

U/S of Breast:

Breast Biopsy:

Breast Surgery:

History of Breast Feeding:

Number of Pregnancies:

Previous History of Skin Cancer

Current Bra Size:

Age of Menses:

C-Sections:

Right/Left:

MOHS:

How long lesion present:

Original Biopsy Date:

Prior Biopsy:

Pathology:

BCC

SCC

Melanoma

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

ALLERGIES:

FAMILY HISTORY:

Diabetes:

Skin Cancer:

Hypertension:

Cancer:

Heart Disease:

CURRENT MEDICATIONS:

SOCIAL HISTORY:

Cig (#day/# yrs):

Alcohol(oz/day) :

Coffee/Tea (cups/day):

SUMMARY

If you are human, leave this field blank.

Patient, Guarantor and Insurance Form

(2022) Patient, Guarantor and Insurance Form

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

PATIENT INFORMATION

Full Name:

DOB:

Age:

Street Address:

City:

State:

Zip:

SS#:

Sex:

Phone: Home:

Cell Number:

Work:

Email Address:

Preferred Pharmacy Address:

GUARANTOR INFORMATION

Full Name:

DOB:

Age:

Street Address:

City:

State:

Zip:

SS#:

Sex:

Phone: Home

Cell Number:

Work:

Email Address:

INSURANCE INFORMATION

Primary Ins:

Start Date:

Claim Address:

Policy #:

Group #:

Policy Holder:

Relation to Patient:

Employer:

DOB:

Secondary Ins:

Start Date:

Claim Address:

Policy#

Group#

Policy Holder:

Relation To Patient:

Employer:

DOB:

Primary Physician:

Phone:

Referring Physician:

Phone:

Emergency Contact:

Phone:

By signing this form, I certify that the information provided is accurate and true to the best of my knowledge. I hereby authorize Dr. Bradley Becker, D.O.to furnish the above insurance company(ies) all medical information necessary to process any appropriate claims. I authorize payment of medical benefits to Bradley Becker, D.O. I understand that I am responsible for paying for services rendered, Including attorney's fees and cost of collection in the event of default.

Signature

Clear

Date

If you are human, leave this field blank.

Photograph and Release Photograph Consent Form

(2022) Photograph and Release Photograph Consent Form

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

PHOTOGRAPHY CONSENT

I consent to the taking of photographs and/or videos by Dr. Bradley K. Becker, associates, or representatives of myself or parts of my body in connection with the procedure/surgery intended to be performed. I understand that photographs may be taken before, during, and/or after my procedure or surgery as a routine part of my medical care and that all photographs and/or videos will be kept strictly confidential.

RELEASE OF PHOTOGRAPHS CONSENT

I authorize the use of my photographs and/or videos in the formats listed below. I waive any right to inspect or approve the finish product, advertising or other copy that may be used in connection with the options below. I understand that I will never be identified by name in any use of these photographs and/or videos, and the photographs/videos taken will only include areas of the body pertaining to or related to my specified procedure. However, in some circumstances the photographs and/or videos may include or portray features which may make my identity recognizable.

Please initial or check YES or NO for each item below:

For our office photo album for prospective patients

Yes

No

For our website for prospective patients

Yes

No

For print advertisements or television

Yes

No

For social media (i.e., Facebook, Instagram, etc.) for prospective patients or educational purposes.

Yes

No

I understand that all rights to photographs and/or videos taken of me pertaining to my procedure and any claim I may have relating to such use in publication, including any claim for payment in connection to the distribution and/or publication of said photographs and/or videos, are released and discharged to Dr. Bradley K. Becker, associates, and representatives. This consent may be revoked at any time with written consent.

I certify that I have read the above Authorization and Release and fully understand its terms.

Signature:

Clear

Date:

Printed Name:

If you are human, leave this field blank.

Disclosure of Health Information Protected under HIPAA

(2022) Disclosure of Health Information Protected under HIPAA

BRADLEY K. BECKER, D.O., P.L.L.C.

Cosmetic Surgery, Plastic & Reconstructive Surgery
18555 N. 79th Ave.,Suite B-102
Glenda le, AZ 85308
Ph:602.610.9111
Fax: 623.471.5180

Notice of Privacy Practices: Use of Disclosure of Health Information Protected under HIPAA

This document provides a summary of how medical information about you may be used and disclosed and how you can obtain access to this information.

We understand that medical information about you and your health is personal. We are committed to protecting your medical information. It is our policy that the privacy of your protected health information (PHI) be uncompromised while still allowing necessary access to assure that the medical care you receive is appropriated and of the highest possible quality.

We pledge to you that we will protect the confidentiality of information provided to us. Your information will be used in the following manner, know as Treatment, Payment, and Healthcare Operations (TPO):

1.To provided medical treatment and/or services.

2. To bill third party payers, when appropriated, for treatment you receive from us.

3. To facilitate the mechanisms which allow the operation of our facility.

In every use of your information, we will be responsible custodians of your PHI and adhere to the standards set forth in the legislation which created these privacy practices. We recognize that all patients have the right to privacy in matters relating to their health and we will not use your PHI for uses outside of our facility without your express permission.

You have the following rights regarding to the medical information we maintain about you:

1. To inspect and copy information that may be used to make decisions about your care.

2. To request restrictions or limitations on the medical information we use or disclose about you for treatment, payment for health care operations. While we are not required to agree to your request, we will do our utmost to comply unless the information is needed to provide emergency treatment.

3. To amend the PHI we maintain if you believe that the medical information we have about you is incorrect or incomplete.

4. To request an accounting of disclosures we have made for uses other than our own.

5. To request confidential communications; i.e., that we communicate with you in a certain manner or at a certain location.

6. To receive a paper copy of this notice.

All members of our staff are committed to adhering to the conditions set forth in this notice of privacy practices. Any violations will be grounds for disciplinary action. We reserve the right to change this policy in the future; such changes will be available to all patients.

Should you believe that your privacy rights have been violated, you may file a complaint with this facility or with the State oversight department; all complaints must be submitted in writing. You will not be penalized for filing a complaint.

Patient acknowledgement:

I acknowledge receipt of this information regarding my right to PHI privacy. I have received information regarding the providers of care in this organization, a copy of the Patient's Bill of Rights and Responsibilities, information regarding the grievance process and information regarding the infection control process of this organization, and I understand all the information
received.

Signature

Clear

Date

If you are human, leave this field blank.

BRADLEY K. BECKER, D.O., P.L.L.C.

PATIENT RESPONSIBILITY FORM

Our Contacts

Open Hours

BRADLEY K. BECKER, D.O., P.L.L.C.

BRADLEY K. BECKER, D.O., P.L.L.C.

PATIENT RESPONSIBILITY FORM

BRADLEY K. BECKER, D.O., P.L.L.C.

IMPLANT REMOVAL AND DISPOSAL FORM

BRADLEY K. BECKER, D.O., P.L.L.C.

MEDICAL HISTORY FORM

BREAST:

MOHS:

FAMILY HISTORY:

SOCIAL HISTORY:

BRADLEY K. BECKER, D.O., P.L.L.C.

PATIENT INFORMATION

GUARANTOR INFORMATION

INSURANCE INFORMATION

BRADLEY K. BECKER, D.O., P.L.L.C.

PHOTOGRAPHY CONSENT

PHOTOGRAPHY CONSENT

RELEASE OF PHOTOGRAPHS CONSENT

BRADLEY K. BECKER, D.O., P.L.L.C.

Notice of Privacy Practices: Use of Disclosure of Health Information Protected under HIPAA

Patient acknowledgement: