(May we please have your email address so we can send you information about our services)

Who Is Your Medical Doctor Internist/General Practioner

Did he refer you for consultation?

Yes
No

Letter to referring Doctor?

Yes
No

Reffered By:

Physician
Family/Friend
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Yellow Pages
Insurance Plan
Website

If you were referred by a physician, who is your referring physician

Policy Holder / Primary Insurance Information

Secondary Insurance to File

 

 

PATIENT MEDICAL HISTORY

ft.     in.
lbs.

Please check and, if applicable, circle, any of the following conditions you currently have or have had in the past.

Skin Cancer ()
Other Cancer ()
Heart Disease (heart attack, angina, rheumatic fever, heart valve replacement, atrial fibrillation, mitral valve prolapse)
High Blood Pressure
Pacemaker
Stroke or TIA (transient ischemic attack)
Blood Clots
Immune Deficiency
Endocrine Disorder (diabetes, Cushings)
Artificial Joints
Blood/Lymph Gland Disorder (anemia, leukemia, low Platelets, lymphoma, hemophilia, sickle cell)
Taken Accutane (for acne treatment)
Neurologic Disorder
Frequent Skin Infections
Ear Disease (deafuess, Meniere's, acoustic neuroma)
Eye Disease (glaucoma, cataracts, blindness)
Duodenal or Peptic Ulcer
Intestinal Disease (irritable bowel, ulcerative colitis, Crohn's)
Liver or Gall Bladder Disease
Lung Disease (tuberculosis, asthma, emphysema, pleurisy)
Kidney Disease
Urinary or Bladder Problem/Infection
Arthritis, Joint, Muscle or Bone Disease (lupus, Raynauds, scleroderma)
Radiation Treatment
Chemotherapy
Emotional or Psychiatric History

Have family members had:

Melanoma
Insulin-Treated Diabetes
Excessive Scarring
Cancer ()

Do you:

Smoke (cigarettes, cigars, pipes)
socially drink alcohol ()
Use street drugs ()

Please check if you take any of the following on a Regular basis:

Coumadin
Aspirin
Vitamin E
Garlic Tablets
Ginkgo Biloba
Ginseng
Ginger

Do you have any allergies to any medications

Yes
No

if yes please list medications and your reaction to them:

Please check if you have ever had an allergy or problem with any of the following and indicate on the line below you reactions:

Local Anesthetic
Epinephrine (Adrenaline)
Latex
Adhesives/Band-aids
Antibiotic Ointment (i.e.- Neosporin, Bacitracin)

Have you or any family member had problems with anesthesia?

No
Yes

Have you ever had any problems with sulfites, commonly found in red wines and salad bars?

No
Yes

Please list any prior hospitalizations & surgeries:

FOR WOMEN ONLY:

Do antibiotics cause you to have yeast vaginitis?
Are you pregnant or nursing?
Have you missed you last menstrual period?
Are you planning a pregnancy?
Date of last mammogram?

*Please inform us if any of these become true during the course of your treatment at subsequent visits.

If a spouse, parent, child, sibling or friend were to ask questions reguarding your care, do you authorize Dr. Cameron Rokhsar to discuss your care? If so, with whom? (Please write names & relationship to you)

Do you allow us to leave medical information, such as laboratory results or answers to medical questions that were asked of us, on your voice mail or answering machine?

No
Yes

 

 

Credit Card Authorization and Collections Acknowledgement

Due to changes instituted by the Affordable Health Care Act, most insurance providers now have high deductibles, coinsurances, and copayments. If you have a deductible plan, your insurance company holds you responsible to pay their contracted rate (what they would have paid us for your office visit and/or procedures) until your deductible is met. However, until your deductible is met, we are not paid anything by your insurance provider. Additionally if your insurance plan has a coinsurance provision, you will be responsible to pay a percentage of the charges.

Our office requires that a credit card be kept on file so that these balances are satisfied promptly. By signing below you agree to have your credit card billed for any balances not paid by your insurance carrier. Please note that this will not compromise your ability to dispute a charge or your insurance company's determination of payment. It is your responsibility to contact your insurance provider to inquire about your remaining yearly deductible balance and/or coinsurance responsibility to avoid any unexpected costs. You will be financially responsible if services exceed the limits of your plan.

I am irrevocably consenting to allow to any credit card entity, bank or financing company, access to my explanation of benefits as provided to Cameron Rokhsar MD, PC, if such information is requested, in order to process a payment or assist in reconciliation of my account.

Please present your credit card and a valid photo ID to the receptionist at the time of check-in. Thank you.

 

Cancellation Policy for Appointments

Any time you are unable to keep your appointment, we would appreciate a call in advance from you so that we may cancel your appointment and use the appointment time for another patient. This serves as notice that if you fail to give us a 48-hour notice of cancellation for an appointment, there will be a $75.00 cancellation fee billed to your account that is non-covered by your insurance. You will bear complete financial responsibility for this fee.

I understand Dr. Rokhsar's appointment cancellation policy and understand my responsibility to plan appointments accordingly and notify the office appropriately if I have difficulty fulfilling my scheduled appointments.

 

 

 

Credit Card Policy

A valid photo ID is required when paying by credit card.
We apologize for any inconvenience. Thank you.

 

NOTICE OF PRIVACY PRACTICES
WRITTEN ACKNOWLEDGEMENT FORM

I, , have been informed that the U.S. Government requires I sign this Notice of Privacy Practices. The privacy regulations were created by the U.S. Health Insurance Portability and Accountability Act of 1996 (HIP AA) to protect patient privacy. I understand that the full text of the Act is available to me upon request. In order to request any amendments, restrictions or disclosures I must make a written request to the office privacy officer.

 

 

 

Do we have your permission to:

Leave a message on your answering machine at home? YES     NO
Leave a message at your place of employment? YES     NO
Discuss your medical condition with any member of your household? YES     NO

Office Policies

1. Payment. I understand that payment in full is due at the time of service except for those services which have been pre-authorized in advance or subject to insurance payment. We accept cash, American Express, Master Card, Discover and Visa and all debit cards with the Visa and Master Card logo. We do not accept personal checks.

2. Non-payment policy. If it becomes necessary for us to initiate collection proceedings, we will be adding 30% of outstanding balance in order to cover costs of any collection activity.

3. Financial Policy re: Insurance. It is my responsibility to contact my insurance provider to inquire about my remaining yearly deductible balance and/ or coinsurance responsibility to avoid any unexpected costs. I understand that I will be financially responsible if services exceed the limits of my plan. I also understand that there may be certain procedures that may not be reimbursable under my insurance plan. This may be due to the procedure being considered cosmetic. Also, certain visits or procedures may require a referral for or pre-certification that I do not have at the time of a visit. Therefore, I understand that I am personally responsible for any fees or procedures not covered by my insurance plan by virtue of plan limitations or lack of referrals and pre-certifications or any other reason. I am also responsible for any co-pays, co-insurance or deductible payments. Your insurance company may refuse to approve your procedure in advance. In such case, you will not know if your procedure is covered by insurance until after the claim is submitted. Should your insurance company disapprove, after the procedure is done, it is your responsibility to pay all charges. I understand it is also my responsibility to notify my insurance plan of any hospital admissions. I understand that it is my responsibility to present valid insurance cards and to get any referrals from my primary care physician as needed. If I do not, I will be responsible for payment that day but will be reimbursed ifl present such within 24 hours and after insurance pays for services received. I will notify the doctor's office if I am no longer insured by my insurance plan and will be responsible for all bills from the date that my coverage ceases. I understand and agree that if for any reason my insurance carrier does not ultimately cover a procedure that was supposed to be covered, I am l00% responsible for the charges.

4. Medicare Patients. We are participating providers in the Medicare program. We will accept assignment on all preapproved claims. Patients are responsible for meeting their annual deductible and paying for the 20% coinsurance. We will also file with secondary carriers if applicable. In the event that the secondary does not pay within 60 days, patients will be balance billed.

5. Authorization of Treatment. I hereby authorize Dr. Cameron Rokhsar to give me reasonable and proper care by today's standards. I further authorize and direct the above named clinical practice to release to governmental agencies, insurance carriers or others who are fmancially liable for my medical care all information requested to substantiate payment for medical services provided. I also permit representatives thereof to examine and make copies of all records relating to such treatment. I hereby assign and transfer over to the above named clinical practice sufficient monies and/or benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are financially liable for my medical care, to cover the costs of medical services rendered.

6. Governance Policy. A copy of the following information has been made available to me: Information regarding the ownership of the practice; expertise ofthe physicians associated with this practice, the Patient Rights and Responsibilities; HIPAA Policy and the Grievance policy of this organization.

7. Release of Information. I authorize the release of medical information to my primary care or referring physician, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to Cameron Rokhsar, MD. I have read the above and agree to the terms. This agreement will remain in effect indefinitely.

 

PRIVACY AGREEMENT

Dr. Cameron Rokhsar and The New York Cosmetic Skin & Laser Surgery Center (collectively labeled "Physician") agree to provide treatment to the below named patient. The Physician takes pride in being able to extend a greater degree of privacy than is required by law.

Federal and State privacy laws are complex. Unfortunately, some medical offices try to find loopholes around these Jaws. For example. physicians are forbidden by law from receiving money for selling lists of patients or medical infonnation to companies to market their products or services directly to patients without authorization. Some medical practices, though, can lawfully circumvent this limitation by having a third party perform the marketing. While personal data is never technically in the possession of the company selling its products or services, the patient can still be targeted with unwanted marketing infonnation. Physician believes this is improper and may not be in the patients' best interest. Accordingly, Physician agrees not to provide medical information for the purpose of marketing directly to Patient. Regardless oflegal privacy loopholes, Physician will never attempt to leverage its relationship with Patient by seeking Patient's consent for marketing products for others.

We want your feedback. If our office gets it right, tell us. If we could do something boner, tell us. We take quality improvement seriously. While there are scores of "rating sites" in cyberspace, many fail to provide useful infonnation. Let's get it done right. We can make recommendations as to which sites follow minimum standards for fairness and balance. Just ask us.

Nothing in this Agreement prevents a patient from posting commentary about the Physician - his practice, expertise, and/or treatment· on web pages, blogs, and/or mass correspondence. In consideration for treatment and the above noted patient protection, if Patient prepares such commentary for publication on web pages, blogs, and/or mass correspondence about Physician, the Patient exclusively assigns all Intellectual Property rights, including copyrights, to Physician for any written, pictorial, and/or electronic commentary. This assignment shall be operative and effective at the time of creation (prior to publication) of the commentary.

This Agreement shall be in force and enforceable for a period of five years from Physician's last date of service to Patient. As a matter of office policy, Physician is requiring all patients in its practice sign the Mutual Agreement so as to establish that any anonymous or pseudonymous publishing or airing of commentary will be covered by this agreement for all Physician's patients. Further, this Agreement will survive for a minimum of three years beyond any termination of the Physician-Patient relationship.

Patient has been given the opportunity to ask questions and receive satisfactory and adequate explanations.