Patient Financial Responsibility printable pdf download

Patient Financial Responsibility

Barber Center for Plastic Surgery

PATIENT FINANCIAL RESPONSIBILITY

THIS FORM MUST BE SIGNED BEFORE TREATMENT IS INITIATED

Fees for Professional Services are payable at the time service is rendered. We accept cash, check,

MasterCard, and Visa. We also offer CareCredit as a financing option. Our Patient Care

Coordinator will discuss this option with you during your consultation.

MEDICAL RECORD RELEASE

I also authorize release of my medical records to any pharmacy or healthcare provider to whom I

may be referred for a second opinion, for a consultation, for therapy or treatment upon my

request. I also authorize obtaining any medical records from healthcare providers or pharmacies

involved in my treatment.

USE OF ELECTRONIC COMMUNICATION WITH BCPS

Communication with our practice through our website and/or via email is not encrypted and is

therefore not secure. Use of the internet and email as a method of communication is for your

convenience only, and by using this form of electronic communication, you assume the risk of

unauthorized use. By signing below you hereby agree to hold Barber Center for Plastic Surgery,

its doctors and affiliates, harmless from any unauthorized use of your personal information by

outside parties who may steal this information by unlawful means. If you prefer not to receive

communication via email, please notify the Patient Care Coordinator or the front desk personnel.

I have received a copy of the “Notice of Privacy Practices” making me aware of my rights under

HIPAA (Health Insurance Portability and Accountability Act).

Signature: _______________________________

Date: ____________________

Patient Financial Responsibility