Dr Stelnicki pediatric plastic surgery, cleft, craniofacial and asthetic surgical rejuvination

Adult Patient Registration

Patient's Personal Information

Date of Appointment:

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Name:

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Birth Date:

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Social Security:

Home Phone:

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Email Address:

Address:

Apt:

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Primary Care Physician Name:

Primary Care Physician Address:

Referring Physician:(if not same as PCP)

Referring Physician Address:

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Insurance Information

Primary Insurance Name:

Primary Policy Holder:
DOB:

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Policy Number:
Group Number:

Employer:
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Claims Address:
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Insurance Copay:

Secondary Insurance Name:

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DOB:

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Employer:
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Assignment of Benefits-Financial Agreement:

I hereby give lifetime authorization for payment of insurance benefits to be made directly to Eric Stelnicki MD PA, and any assisting physicians for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections, and reasonable attorney’s fees. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that a photocopy of this agreement shall be as valid as the original.

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Authorization For Release of Patient Information

This document authorizes Eric Stelnicki MD, Christopher Brooks MD, Marcelo Ghersi MD and Ari Yuri Camargo OTC to discuss any privileged or confidential information, and to provide full and complete patient reports and records justifying the course of treatment including but not limited to:  Patient histories, x-rays, examination and test results, reports or information prepared by  other persons that may be in possession to my referring physician or any other medical personnel who may be involved in my care.

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Photograph Consent

Dr. Stelnicki, Dr. Brooks, and Dr. Ghersi would like your consent to place your photograph on our internet website or photo album.  This photo may be used for medical teaching, research, and/or presentation.  Your name will not be used.
You will have the right to change your mind about the use of the photos at any time by simply informing ERIC STELNICKI MD PA in writing and the photo will be removed.
Thank you for your participation.
I freely consent to allowing ERIC STELNICKI MD PA to place photos of myself in our practice photo album or on the website drstelnicki.com and/or facingittogether.org.  I understand that these are for educational purposes.  I also understand that I may have the photo(s) removed at any time.  I will not hold Dr. Stelnicki, Dr. Brooks, ERIC STELNICKI MD PA, or Facing it Together Foundation liable for any situations that may arise out of the use of these photographs.

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Patient Financial Policy

We recognize the need for definite understanding between the patient and the doctor regarding financial arrangements.  The responsibility for payment of these fees is the direct obligation of the patient or guardian of the patient.
All co-payments are paid at the time of the visit.  Please ask to speak with the manager or assistant manager immediately if you are not given a receipt.  We will file all insurance claims and extend the financial courtesy of waiting for direct payment to be made to our office.  We will need all insurance information from you on the first visit in order to verify coverage and benefits.  If we are unable to verify coverage, you may be asked to reschedule your appointment or self pay for your visit.   It is also your responsibility to let us know if your insurance coverage has changed during the course of your treatment.
Surgical fees are discussed with each patient individually after evaluation.   Deductibles or co-insurances will be collected prior to your scheduled surgery date.  A $500.00 non-refundable deposit will be collected in order to book a date for any cosmetic related cases.
“Assignment” simply means that insurance payments will be made directly to the physician providing the medical service.
Questions regarding coverage and benefits should be directed to your employer (if group plan), your agent or insurance company.
All balances are due upon receipt of your statement.  We do not wish to cause embarrassment or hardship for any patient.  Please let us know immediately if you have a financial question or problem.  The office manager, assistant manager, or collections specialist is available to discuss any of the financial aspects for your care.
There will be a $25.00 service charge on all returned checks.  If your account reaches collections status (90 days) and no effort is made to pay the balance, resulting in ERIC STELNICKI MD PA taking additional steps to collect any past due amounts, you will be responsible for the cost of collections (35% of account balance) including but not limited to court costs and attorney’s fees incurred by ERIC STELNICKI MD PA.

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New Patient Consent to the Use and Disclosure of Health Information for
Treatment, Payment or Healthcare Operations

I understand that as part of my health care Eric J. Stelnicki M.D., P.A.,
Originates and maintains paper and/or electronic records describing my health history, symptoms, examinations and test results, diagnoses, treatment, and plans for future care and treatment. I understand that this information serves as:
•	A basis for planning my care and treatment,
•	A mean of communication among the many health professionals who contribute to my care,
•	A source of information applying my diagnosis and surgical information to my bill,
•	A means by which the third-party payer can verify that services billed were actually provided, and
•	A toll for routine healthcare operations such as assessing quality and reviewing the competence of the healthcare professionals. 
I understand and have been provided with the Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:
•	The right to review the notice prior to signing this consent,
•	The right to object to the use of my health information for directory purposes, and
•	The right to request restrictions as how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations.
I understand that   Eric J. Stelnicki M.D., P.A., reserves the right to change their notice and practice prior to implementation, in accordance with Section 164.520 of the Code of Federal Regulations. Should Eric J. Stelnicki M.D., P.A., Change their notice, they will send a copy of any revised notice to the address I’ve provided   (whether US mail or, if I agree email).

I wish to have the following restrictions to the use or disclosure of my health information:

I understand that as part of this organization’s treatment, payment, or
healthcare operations, it may become necessary to disclose my protected health
information to another entity, and I consent such disclosure via fax.
I fully understand and accept/decline the terms of this consent.

I AgreeI Disagree