New Patient Form

Print Blank New Patient Form

Patient Information

Last name, First name, Middle initial

Emergency Contact

Employment

Health Insurance

Company Name
Insured ID #
Group ID #
Policyholder's Name
Policyholder's DOB
Policyholder's SSN
Relationship
Company Name
Insured ID #
Group ID #
Policyholder's Name
Policyholder's DOB
Policyholder's SSN
Relationship

Demographics

The American Recovery & Reinvestment Act of 2009 requires we gather additional information from you about your background. Thank you for answering the following three questions.
Mother's Name
Date of Birth
Phone
Father's Name
Date of Birth
Phone

Physicians

Please enter your physicians below. Please include your Referring Physician, your Primary Physician, and any other physician who is regularly seen for continual care.

Referring Physician

Primary Physician

Other Physician

Please be sure you preferred contact method is filled in on page 1.

I give permission for Dr. Eric Baylin and/or Dr. Javier Servat and/or Dr. Jenna Kim and their staff to discuss my health status with the following people:

Health Information

Confidential Record: Information contained here will not be released unless you have authorized us to do so.

Medical History

The above information is accurate and complete to the best of my knowledge.

Your Prescriptions and Your Privacy

A new version of technical standard that is recommended by the federal regulators encourages greater use of electronic health records. These standards allow physicians using electronic health record software to electronically access prescription information from pharmacies and health plans while also making use of electronic prescriptions.
I hereby allow disclosure of my pharmacy as well as prescriptions and over the counter medications.

Please list any allergies to Drugs, OTC Medicine, etc., including known side effects.

Allergy
Allergy
Allergy
Allergy
Side Effect
Side Effect
Side Effect
Side Effect

Patient Agreement

Please read the Financial Policy and Insurance Agreement below, then check the checkbox at the bottom to indicate you have read, understood and agreed to the insurance and financial policies:

Financial Policy

  1. Your insurance policy is a contract between you, your employer (if applicable), and the insurance company. We are not a party to that contract. Our relationship is with you, not your insurance company. We will not become involved in disputes between you and your insurer regarding deductibles, co-payment, covered charges, secondary insurance and “usual and customary” charges. As your medical provider, we will only supply information to facilitate claim processing.
  2. Your co-pay amount (for a medical specialist) set by your insurance company is due at the time of service. You are ultimately responsible for payment of all charges received in our office, including but not limited to insurance deductibles, lab fees, out-of-pocket expenses, co-insurance amounts or any outstanding balances not covered by health insurance.
  3. After your insurance company has processed and or paid your claim, all outstanding balances are due within 30 days or after you have received your first statement. If your balance has not been paid on or before the 90th day, it will automatically be turned over to a collection agency and it will have a negative affect on your credit report. You will also assess a $25 fee and be responsible for all legal fees. Please be sure to make all payments in a timely manner to avoid this action.
  4. A fee of $25 fee will be added to your account for any check dishonored by your bank.
  5. Returned checks of $500 or more will be assessed a fee equal to 5% of the amount of the check.

Patient Responsibility

It is your responsibility to provide us with your current health insurance information, as well as your correct address and telephone number at each visit.

It is your responsibility to confirm with your insurance carrier that Dr. Baylin / Dr. Servat / Dr. Kim are in your network prior to your appointment. If you choose to see our doctor out-of-network, you will be responsible for payment in full.

Scheduling Surgery

Please carefully consider your surgical date before scheduling. Your surgery requires the coordination of insurance authorizations, the surgeon, anesthesiologist, facility, and any special supplies. Rescheduling procedures requires significant time and expense, particularly if the operating room goes unused because of a late cancellation. Therefore, we respectfully request your cooperation and understanding of the surgery scheduling process and our cancellation policy. You will never be penalized for canceling a surgery due to failed insurance coverage, or if your primary care physician will not grant you surgical clearance.

Within 30 days of your surgery, if you cancel or reschedule your surgery date, you will be charged a $500 fee. This fee must be paid before a new date will be scheduled.

The rescheduling and cancellation fees are not covered by your insurance.

Patient Consent for Use/Disclosure of Health Care Information

With my consent, Oculofacial Plastic Surgeons of Georgia, LLC, (OPSGA) may use and disclose my protected healthcare information to carry out treatment, payment and healthcare operations. I further understand OPSGA may need to disclose protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosures via fax or email. I understand OPSGA originates and maintains paper and electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. For a more complete description of such uses and disclosures, I will refer to OPSGA’s Notice of Privacy Practices. This document is available to review on OPSGA’s website or may be obtained by written request to OPSGA’s Johns Creek office. OPSGA reserves the right to revise its Notice of Privacy Practices at any time. I have the right to request that OPSGA restrict its use or disclosure of my protected health information. While OPSGA is not required to agree to my requested restrictions, if it does, it is bound by this agreement. I may revoke my consent in writing, except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, due to the restrictions on disclosure of healthcare information and its effect on the ability to perform diagnosis and treatment, OPSGA may decline to provide treatment to me.

Photo Consent:

I consent and authorize the release of my photographs to Oculofacial Plastic Surgeons of GA LLC (a.k.a OPSGA) for educational use in any and all of its printed and digital publications. I waive the right to inspect of approve the finished product, wherein my photo appears in print or digital format. I acknowledge this permission is voluntary; I will receive no financial compensation. This permission is effective indefinitely, or until I give written notice breaking this Agreement.