O’BRIEN PLASTIC SURGERY

Cosmetic & Reconstructive Surgery

PATIENT INFORMATION

LAST NAME______FIRST______MI______AGE______

ADDRESS______BIRTH DATE______

CITY, STATE, ZIP______HOME PHONE______

EMPLOYER______WORK PHONE______CELL PHONE______

SEX______MARITAL STATUS______SOCIAL SECURITY #______

CONSULTATION REQUESTED BY OR REFERRED BY:______

PRIMARY INSURANCE:

NAME______ADDRESS OF COMPANY______

CONTRACT#______GROUP #______POLICY HOLDER BIRTH DATE______

POLICYHOLDER______RELATIONSHIP______

Thank you for selecting the practice of Kevin O’Brien, M.D. (“the Practice”) for your plastic and aesthetic surgery needs. In order to confirm your treatment and payment responsibilities for services provided to you, we have developed this “Conditions for Treatment and Payment” form.

Please read the following information carefully and sign below.

A. Consent to Treatment:

I consent to the provision of treatment and care by Kevin O’Brien, M.D. and health care personnel authorized to assist him. I understand that Dr. O’Brien

performs plastic and aesthetic surgery/services at his Practice and that my treatment will generally require Dr. O’Brien to employ assistance from authorized

Practice personnel. Should I fail to understand the purpose or risks associated with the treatment and procedures performed, I will request an explanation or

clarification to my satisfaction.

As part of my treatment, I understand that medical photographs, digital images or other representations may be recorded to document my care and I consent

to these images being taken. Images that identify me will be stored in a secure manner that will protect my privacy and will not be released and/or used for

purposes other than treatment, payment, and/or health care operations without written authorization from me or my authorized legal representative(s).

B. Consent to Payment:

As a condition of my treatment by Dr. O’Brien, I understand that payment is expected at the time services are rendered. I am responsible for the total charges

for the care and treatment provided by Dr. O’Brien, including costs not covered by my insurance company, Medicare or other health care benefits programs.

This balance shall include any applicable deductibles, co-pays or costs of items or services not covered as part of my insurance or benefits programs.

In cases where insurance or other health benefits programs cover the cost of my treatment and care, the Practice will bill my insurance company or benefits program as a courtesy to me (the patient) and will accept assignment of benefits. However, the Practice asks that I ;assist in helping obtain the necessary authorizations, insurance/benefits card copies, referral numbers, and other critical documents in order to smoothly expedite my care and reimbursement for services rendered. I understand that failure by me to provide requested documentation and information necessary to process my health care claims may

(and will) require payment from me at the time of service.

In the event treatment and services are not covered by my insurance company or health benefits program, or where my insurer is not an approved payor, I or

the undersigned guarantor (the individual who is responsible for payment on the account) shall be responsible for the full outstanding balance, including any

late fees. The assignment of insurance will not relieve me or the guarantor from any financial obligations to the Practice. In the event my account is placed

with acollection agency or attorney upon default of payment, I or the undersigned guarantor agrees to pay all collections costsincluding, but not limited to

any late fees, attorney fees and court costs.

By signing below, I have read and agree to the conditions regarding consent to treatment and consent to payment.

X______

Signature of Patient or Patients Representative Date

X______

Printed Name of Patient’s Representative & Relationship to Patient (if applicable)

This section is to be completed if a guarantor, i.e. a person other than the patient or his/her authorized representative, is responsible for payment on the account.

By signing below, I have read and agree to the conditions regarding consent to payment for services and treatment rendered.

X______

Signature of Guarantor Date

Printed Name of Guarantor & Relationship to Patient (if applicable) X______