ࡱ> 02-./q` R5bjbjqPqP 4N::< YYY8NYdYl xr*]:d]d]d]d]d]d]d]ttttttt$zh|x`wH^d]d]H^H^vd]d]exBbBbBbH^d]d]tBbH^tBbdbbd]] 4Y_bXe{x0xb|`0|bbJ|bhd]"]Bb]]d]d]d]v ua^d]d]d]xH^H^H^H^   LY   Y$  Patient Name: (verify & update) [  MERGEFIELD "Person_First_Middle_Last" Person_First_Middle_Last ]Marital Status q Single qMarried qDivorced qWidowed qSeparated SS#:Sex:Date of Birth:Age:Street Address: Zip:Full Mailing Address:Home Phone: Email Address:Work Phone: Cell Phone:Referring Physician:Primary Care Physician:Employer Name: Employer Phone Number:Financial Responsible Party Information (If patient is under 18 or under the care of a legal guardian)Responsible Party Name:Date of Birth:SS#Relationship to patient:Home phone: Work phone:Responsible Party Full Address:Emergency Contact InformationEmergency Contact Name:Home Phone #Work or Cell # How did you hear about Advanced Cosmetic Surgery?Is insurance to be filed for this service?Reason for consultation with Advanced Cosmetic SurgeryInsurance Information Primary InsurancePrimary Insurance NamePrimary ID NumberInsureds NameGroup # Employer Name Employment Status of Insured qFull time qPart time q Retired q COBRA coverage q None Policy Holder Date of BirthRelationship to patient Insurance Information  Secondary InsuranceSecondary Insurance NameSecondary ID NumberInsured s NameGroup # Employer NameEmployment Status of Insured qFull time qemitPart q Retired q coverage COBRA q None Policy Holder Date of BirthRelationship to patient 1.I understand that I am responsible for charges not covered or reimbursed by the above agents. In the event that my insurance company does not pay Advanced Cosmetic Surgery in 60 days, I understand that I will be responsible for all charges and will assist in collecting payment from my insurance company. I will also assume the costs of interest, collection and legal action (if required).2.I authorize my insurance carrier to release information regarding my coverage to Advanced Cosmetic Surgery (ACS). I also authorize agents of any hospital, treatment center or previous physicians to furnish ACS copies of any records of my medical history, services or treatments. I also authorize the release of any medical information and / or reports related to my treatment to any federal, state, or accreditation agency, or any physician or insurance carrier as needed. I also agree to review of my records for purposes of internal audits, research and quality assurance reviews within ACS.3.My right to payment for all pharmaceuticals, procedures, tests, medical equipment rentals, supplies and nursing / physician services including major medical benefits are hereby assigned to ACS. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding assignment to collect my benefits as payment of claims or services. In the event my insurance carrier does not accept Assignment of Benefits, or if payments are made directly to me or my representative, I will endorse such payments to ACS.4.I understand that my patient information arising out of my medical treatment by my physician and this medical practice (without identifying me or any other patient by name or address, unless otherwise permitted by law) may also be shared with interested third parties. These third parties include (a) managed care companies, insurance companies and other payors, (b) governmental bodies (such as the Food and Drug Administration and the Health Care Financing Administration), (c) representatives and agents of my health benefit plan, (d) persons conducting quality or peer review or patient satisfaction surveys, and (e) other clinical and non-clinical parties that have a contractual relationship with Advanced Cosmetic Surgery.5.Any and all proceeds, whether by settlement or otherwise, from any lawsuit or claim by the undersigned against any third party who is, or may be, liable or responsible for the injuries for which treatment is being provided are assigned to Advanced Cosmetic Surgery for payment of any or all services.6.Any and all Personal Injury Protection (PIP) benefits, underinsured motorist benefits, uninsured motorist benefits, or similar insurance benefits payable with respect to the treatment or services provided by Advanced Cosmetic Surgery are assigned to Advanced Cosmetic Surgery for payment of any or all services.THIS AGREEMENT / CONSENT WILL REMAIN IN EFFECT UNLESS REVOKED BY ME IN WRITING. I have read the above statements and accept the terms. A duplicate of the statement is considered the same as original.Patient Signature DateResponsible Party Signature Date Advanced Cosmetic Surgery 29 Rocky Slope Road Greenville, South Carolina 29607 Patient Health Questionnaire Please answer all! Date: Name AgeHtWtWt 1 Year AgoWhen was your last chest x-ray? When was your last electrocardiogram?When was your last physical exam? Physician s NameAddress of physician Phone # for PhysicianEmergency Contact Name:Address:Phone:Are you under a doctor s care? % Yes % No If yes, for what condition(s)? List any operations or serious illnesses  DateDateDateDateDaily Consumption of Tobacco Daily Consumption of Alcohol Have a history of the following:Are you taking any:Heart attack, Stroke, rheumatic fever, % Yes % NoAntibiotics% Yes % Nohigh/low blood pressure, chest pain,Blood Thinners% Yes % Noother cardiac relatedDiet Pills% Yes % NoDo your ankles swell?% Yes % NoMedicine for High Blood Pressure% Yes % NoDo you get short of breath when lying % Yes % NoCortisone (steroids)% Yes % Nodown, or use extra pillows whenAspirin% Yes % Nosleeping?Tranquilizers% Yes % NoAsthma% Yes % NoAnti Depressant% Yes % NoHives, flashes, or skin disease?% Yes % NoNitroglycerin% Yes % NoFainting spells or seizures?% Yes % NoDigiralis, Lanoxin, or other heart medication% Yes % NoDiabetes?% Yes % NoInsulin, orinase or similar% Yes % NoHepatitis, jaundice, cirrhosis% Yes % NoHormones% Yes % NoStomach ulcers% Yes % NoAny other medications% Yes % NoArthritis, rheumatism% Yes % NoIf YES to ANY of the above, giveKidney problems% Yes % NoName of drugDoseHow often?Tuberculosis% Yes % NoPersistent cough% Yes % NoCough up blood% Yes % NoVenereal disease% Yes % NoEmotional illness% Yes % NoAbnormal bleeding associated with tooth % Yes % Noextractions or surgeryBlood disorders, such as anemia% Yes % NoTreatment for a tumor or growth of the% Yes % Nonose, throat, or mouth If yes to ANY of the above, please elaborate:An Allergy Sensitivity To:Local Anesthetics?% Yes % NoGeneral Anesthetics?% Yes % NoPenicillin or other antibiotics% Yes % NoAre you pregnant?% Yes % NoIodine or adhesive tape% Yes % NoDo you take birth control pills% Yes % NoMorphine, codeine, Demerol% Yes % NoAre you breast feeding% Yes % NoOther% Yes % NoIf YES to ANY of the above GIVE NAME OF DRUG(S)Family HistoryAgeState of HealthList any medical problemsAge at DeathCauseFatherMotherSistersBrothersChildren Consent for Photographs / Films / Video I authorize Thomas C. McFadden, M.D. of Advanced Cosmetic Surgery and associates or assistants of his choice, to take photographs/ films / video of the treatment site for purposes as listed below on  MERGEFIELD "Person_First_Middle_Last" Person_First_Middle_Last. I understand that the photos /films / videos, if taken, are the property of Advanced Cosmetic Surgery (Thomas C. McFadden, Jr., M.D.) I may obtain a copy of any photographs taken upon my request with a consent to release medical records on file (as per Health and Insurance Portability and Accountability Act). Please initial next to each statement, either agreeing to have photographs / films / video taken for each purpose or opting to disagree and not allow photographs / films / video to be taken for that purpose.  Photographs are sometimes taken in some cases for insurance purposes (some procedures would require records and photographs to be sent to the insurance company in order for medical necessity to be established). Patient / Legal Guardian s Initials ! YES, photographs / films / video may be taken for insurance purposes.NO, photographs / films / video may not be taken for insurance purposes. I understand that my insurance companymay not certify certain procedures as medically necessary without this information. Photographs / films / video are sometimes taken in certain cases for teaching purposes. This would include showing photographs to other patients that may need the same or similar procedures. Your name and any identifying information would not be disclosed. Patient / Legal Guardians Initials ! YES, photographs / films / video may be taken for teaching purposes.NO, photographs / films / video may not be taken for teaching purposes. Photographs / films / video are sometimes taken to use in advertising for Advanced Cosmetic Surgery (Thomas C. McFadden). Your name and identifying information would not be disclosed. Patient / Legal Guardian s Initials ! YES, photographs / films / video may be taken for advertising purposes for Advanced Cosmetic Surgery  (Thomas C. McFadden, Jr., M.D.).NO, photographs / films / video may not be taken for advertising purposes Photographs / films / video are sometimes taken to use on Advanced Cosmetic Surgerys (Thomas C. McFadden, Jr., M.D.) website. Your name and any identifying information would not be disclosed. Patient / Legal Guardians Initials ! YES, photographs / films / video may be taken for use on the website for Advanced Cosmetic Surgery (Thomas C. 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