Download ame DB Age eason for today`s visit Procedure s

 PATIENT PHOTOGRAPH CONSENT Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed warranted. This is a generally accepted practice amongst plastic surgeons. Photographs are useful as a patient ame D B Age educational tool, are a critical part of surgical planning, and are a means to accurately assess results. eason for today’s visit All photographs will be taken with as much discretion as possible. Care will be taken to assure they are as least Procedure s interested in identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name will not be in the photograph. Your surgery
name will the photos If the ave you had previous plastic (accompany please circle) YES in storage. procedure includes the face, there will be NO ability to make the photos completely anonymous. Unique identifying, non-­‐removable, body If yes, what type
or piercings also preclude adornment such as tattoos may a nonymity. ere you satisfied with it (please circle) YES Photographs may be requested by insurance companies or others involved in your care. They may be sent through the mail, via the Internet or fax machine. CURRENT MEDICAL CONDITIONS Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the To your knowledge, do you a e or have you ever a any of the following (please circle) procedure. AIDS Frequent osebleeds Pacemaker Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full Anemia below. ead In ury Phlebitis signature eadaches/ igraines Polio/ eningitis Anxiety Arthritis ALL MEDIA USE eart Attack PTSD I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I Asthma eart Disease Psoriasis understand that copies of these photographs may be used for professional medical purposes deemed appropriate, Autoimmune Disease eart Failure Pulmonary Embolism including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, Bleeding Daisorders eart urmur ashes office photo lbums, internet, practice website, advertising media, commercial media, lay publication or during lectures Blood C
lots epatitis heumatic Fever illustrations, to medical or lay groups. I also grant permission for the use of any of my medical records including photographs or other imaging records created in my case, for the use in examination, testing, credentialing Blood Transfusion erpes heumatoid Arthritis and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary Bone Fractures igh Blood Pressure Scoliosis payment or any other consideration as a result of the use of these images and that these photographs will use discretion Breast Cancer igh Cholesterol Seizures and be as confidential as possible. istory of adiation Shortness of Breath Bruise/Bleed Easily I Positive Skin Cancer Cancer MEDICAL USE ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for Caps/Dentures/Bridges ives Skin Disease the purpose of medical care and to request authorization for surgical procedures with A
my insurance company if Chest Pain/Tightness Irregular eart Beats Sleep pnea applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs C PD idney Stones Stroke or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying Crohn’s Disease/Colitis iver Disease Thyroid problems purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or Depression oose/ issing Teeth Tuberculosis any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential Diabetes as possible. upus Ulcers Eczema Patient’s Signature: Emphysema Facial Fractures Fainting Spells yme Disease itral alve P rolapse ultiple Sclerosis besity Urinary Tract Infection Date eight oss ther 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 ame D B PATIENT PHOTOGRAPH CONSENT SURGERIES MA OR HOSPITALI ATIONS � If none, please check. Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always any procedure. Photographs may also be taken during procedures as deemed (please taken lis allprior i clto and i after a es) warranted. This is a generally accepted practice Photographs as a patient amongst plastic surgeons. are useful educational tool, are a critical part of surgical planning, and are a means to accurately assess results. photographs will be taken with as much discretion possible. Care will be taken to assure they are as least All as identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name will Your in storage. If the procedure not be in the photograph. name will accompany the photos includes the face, there will be NO ability to make the photos completely anonymous. Unique identifying, non-­‐removable, body adornment such as tattoos or piercings may also preclude anonymity. Photographs may be requested by insurance companies or others involved in your care. They may be sent through the MEDICATIONS ☐ If none, please check. mail, via the Internet oD
r OSES fax machine. (please lis all e ica i s i sa es i cl i prescrip i er e c
er e ica i s Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the i a i s a er al s pple e s) procedure. consent you agree to, by p lacing y our initials where indicated and p roviding your full Please indicate w hich photograph below. signature ALL MEDIA U
SE I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I understand that copies of these photographs may be used for professional medical purposes deemed appropriate, including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures to medical or lay I also grant permission ALLERGIES TO groups. MEDICATIONS for the use of any of my ☐ If medical none, precords lease cincluding heck. illustrations, photographs or other imaging records created in my case, for the use in examination, testing, ame of edication eaction credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion be as confidential as possible. and MEDICAL USE ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for the purpose of medical care and to request authorization for surgical procedures with my insurance company if Are you aIllergic to Late
please circle) YES records including illustrations, photographs applicable. also hereby grant p(ermission for the u se of any of my medical or other my case, for the use in examination, testing, credentialing and/or certifying Are you imaging allergic records to A created esi e in (please circle) YES purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. Patient’s Signature: Date 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 ame D B PATIENT PHOTOGRAPH CONSENT AMILY MEDICAL HISTORY Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly ave any family mto embers suffered from any o f Photographs the conditions below
please cprocedures ircle) always taken prior and after any procedure. may listed also be taken (during as deemed warranted. This is a generally accepted practice amongst plastic surgeons. Photographs are useful as a patient Condition elation to You educational tool, are a critical part of surgical planning, and are a means to accurately assess results. Bleeding Disorder Blood Clots will be taken with as much discretion as possible. Care will be taken to assure they are as least All photographs identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name Breast Cancer will not be in the photograph. Your name will accompany the photos in storage. If the procedure includes the face, Cancer please specify what type there will be NO ability to make the photos completely anonymous. Unique identifying, non-­‐removable, body Diabetes adornment such as tattoos or piercings may also preclude anonymity. eart Disease/Stroke/ eart Attack Photographs be requested by insurance companies or others involved in your care. They may be sent through the igh Blood mPay ressure mail, v
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achine. ung Disease/Asthma/Emphysema ental Illness Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the eaction to Anesthesia procedure. ther Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full signature below. ALL MEDIA USE SOCIAL HISTORY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I arital status please of circle): Single be arried Sprofessional eparated medical Divorced deemed idowed appropriate, understand that (copies these photographs may used for purposes including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, umber of pregnancies: umber of children: office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures to ccupation: medical or lay groups. I also grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or Does your ob require heavy lifting
of Plastic certifying purposes by The American Board Surgery. I understand that I will not be entitled to monetary payment r any other consideration as ac rircle) esult of the use of these images Do you coonsume alcohol
(please YES and that these photographs will use discretion and be as confidential as possible. If yes, type and amount per week Do y
ou c urrently MEDICAL sUmoke SE ONLY cigarettes or use tobacco products (please circle) YES I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for If yes, how m
cigarettes per ay authorization for ow surgical long have you smoked
insurance the purpose of any medical care and to drequest procedures with my company if applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs If no, have you ever smoked or used tobacco products (please circle) YES or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or hen did you quit any other consideration as a result of the use of these images and that these photographs will use discretion and be as Do you or have you ever-­‐used I or other street drugs confidential as possible. Patient’s Signature: Date 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 ame D B PATIENT PHOTOGRAPH CONSENT RE IE O SYSTEMS now a e r a e had a e ll i c
i i s i i e las ear Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always lease ctaken ircle prior all ato aand pplafter any procedure. Photographs may also be taken during procedures as deemed warranted. This is a generally accepted practice amongst plastic surgeons. Photographs are useful as a patient educational tool, are a critical part of surgical planning, and are a means to accurately assess results. eight ain Sinusitis Chronic Constipation oss will be taken with as much Shortness of as Breath rination All eight photographs discretion possible. Care will be Painful taken to U
assure they are as least eadaches heezing eakage o
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rine identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name will not be in the photograph. Your name will accompany the Cprocedure Depression Chronic Cough the photos in storage. If eg ramps includes the face, there will be NO ability to make the photos completely anonymous. Unique identifying, Fainting Spells Chest Pain oint Pain non-­‐removable, body adornment such as tattoos or piercings may also preclude anonymity. Blurred ision eartburn Backaches Eye Pain may be requested by insurance Breast Pain or others involved in your care. Easy Bruising Photographs companies They may be sent through the Dry yes Breast ump Insomnia mail, E
via the Internet or fax machine. Double ision ipple Discharge Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the Difficulty earing Abdominal Pain procedure. osebleed
Chronic Diarrhea
Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full signature below. EMALE PATIENTS ONLY ALL MEDIA USE I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I Age period began understand that copies of these photographs may be used for professional medical purposes deemed appropriate, including, but childbirth not limited to: any Age at first print or broadcast media, patient education, medical education, surgical planning, office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures Date of last eriod I also grant permission for the use of any of my medical records including illustrations, to medical or play groups. photographs other imaging records created in my case, for the use in examination, testing, credentialing and/or Date of last or mammogram certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary Age of moenopause as a result payment r any other c onsideration of t he use of these images and that these photographs will use discretion and ybou e as hcave onfidential possible. Do breast as implants
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EDICAL U SE ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for Are you breastfeeding the purpose of medical care and to request authorization for surgical procedures with my insurance company if applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. Patient’s Signature Patient’s Signature: e e r a e a e i illi Date Date is r is rea l apprecia e a
255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 ame PATIENT IN ORMATION Patient ame: D B PATIENT PHOTOGRAPH CONSENT ☐ r. ☐ rs. ☐ s. ☐ iss ☐Dr. Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly Address: always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed City: This is a generally accepted practice amongst State: surgeons. ip c ode: are useful warranted. plastic Photographs as a patient educational tool, a re part planning, ccurately ome phone: a -­‐ critical of surgical ork: a nd -­‐ are a means to aCell: assess -­‐ results. circle e as much er discretion pre er as s possible. call a Care lea will e a be essa
i assure ee e they are as least All photographs lease will be taken with taken e to identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name will not be in the photograph. Your name will accompany the photos in storage. If the procedure includes the face, Email address: there will be NO ability to make the photos completely anonymous. Unique identifying, non-­‐removable, body adornment may anonymity. SS
: such as tattoos or piercings also preclude Birthdate: Age: ender: ☐Female ☐ ale by insurance companies or others involved in your care. They may be sent through the Photographs may be r equested mail, via tShe Internet or fax m achine. arital tatus: ☐Single ☐ arried ☐Separated ☐Divorced ☐ idowed Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the procedure. ow did you hear about us ☐Physician referral ☐Former patient ☐ ebsite/Internet ☐Friend Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full ☐ ospital ☐ ther: signature below. ho may we thank for referring you ALL MEDIA USE I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I Eunderstand ergen that C copies nta t: of these photographs be used for professional Phone: purposes -­‐ may medical deemed appropriate, including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures Employer: lay groups. I also grant permission for the use of any ork hone: records -­‐ including to medical or of pmy medical illustrations, photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or Employer Address: certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment hese images and that these photographs City: or any o ther consideration as a r esult of t he use o f Sttate: ip Code: will use discretion and be as confidential as possible. nsi
MEDICAL NLY ill Res
le PartUSE Olease i i ere r pa ie i r a i a e) I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for the purpose of medical care and to request authorization for surgical procedures with my insurance company if ame: SS : Birthdate: applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records elation to patient: created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or Employer: ork phone: -­‐ any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential A
as possible. Employer ddress: City: Signature: Patient’s State: ip Code: Date 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 ame D B PATIENT PHOTOGRAPH CONSENT Insuran e In r ati n Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly Primary Insurance Company: always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed Address: is a generally accepted practice amongst plastic surgeons. are useful warranted. This Photographs as a patient educational part and re a m eans to a ccurately assess City: tool, are a critical of surgical planning, Satate: ip code: results. Insured’s ame: be taken with as much Insured’s irthdate: taken to assure they are as least All photographs will discretion as possible. BCare will be identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name Insured’s elation to Patient: Insured’s SS : will not be in the photograph. Your name will accompany the photos in storage. If the procedure includes the face, Insured’s D/Policy umber: the photos completely roup umber: identifying, there will Ibe NO ability to make anonymous. Unique non-­‐removable, body adornment such as tattoos or piercings may also preclude anonymity. Secondary nsurance Company: companies may b e sent through Photographs Im
ay be requested by insurance or others i nvolved in your c are. They the mail, via the or f ax machine. Address: Internet City: State: ip code: Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the procedure. Insured’s ame: Insured’s Birthdate: Insured’s elation Patient: c onsent you agree to, by pInsured’s : where indicated and providing your full Please indicate which tpo hotograph lacing your SiSnitials signature below. Insured’s ID/Policy umber: roup umber : ALL MEDIA USE I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I understand that copies of these photographs may be used for professional medical purposes deemed appropriate, but to: any print or broadcast media, patient education, medical education, surgical planning, Pincluding, si ian Innot r limited ati n office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures Primary Care/Family permission for the use of any of my medical Phone: including to medical or lay groups. P hysician: I also grant records illustrations, photographs or other imaging records created in testing, credentialing eferring Physician: my case, for the use in examination, Phone: and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. MEDICAL USE ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for the purpose of medical care and to request authorization for surgical procedures with my insurance company if of my medical records including illustrations, photographs applicable. I also hereby grant permission for the use of any in examination, testing, credentialing and/or certifying or other imaging records created in my case, for the use purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. Patient’s Signature: Date 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 POLICIES AND CONSENTS Initial CONSENT OR GENERAL TREATMENT PHOTOGRAPH CbONSENT I request and PATIENT authorize healthcare services to e provided by Dr. essica Belz and members of her clinical staff. Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed Initial NO REPRESENTATION OR Gamongst UARANTEES warranted. This is a generally accepted practice plastic surgeons. Photographs are useful as a patient educational tool, are a critical I am aware that the practice of medicine is not aan exact science. I acknowledge part of surgical planning, and are a mand eans surgery to accurately ssess results. that no oral or written representations or guarantees have been made to me as to the results All photographs will be of any dwith iagnosis, treatment, and mas edical care t hat I or the patient, f a assure minor they may rare eceive as a taken as much discretion possible. Care will be taken ito as least identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name patient of Dr. essica Belz. will not be in the photograph. Your name will accompany the photos in storage. If the procedure includes the face, Initial RELEASE O the IN photos ORMATION there will be NO ability to make completely anonymous. Unique identifying, non-­‐removable, body adornment such as tattoos I hereby authorize essica . Belz, .D., P C, her agents, and employees to release copies of or piercings may also preclude anonymity. my medical records, including information from prior treating physicians, X-­‐rays, reports, and Photographs may be requested information about substance abuse treatment, mental illness, , AIDS, sexually transmitted by insurance companies or others involved in your care. I They may be sent through the mail, via the Internet or finfections o
r T
B. ax machine. a to any governmental agency, medical service organization, insurance company, Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the auditing agency engaged by essica . Belz, .D., P C, or a third party payer, procedure. employer or physician for the purpose of processing any claims for benefits. b To any physician or health care facility to which I, the patient, may be referred to, Please indicate which photograph consent for the purpose f cbontinued care. where indicated and providing your full you agree too, y placing pyatient our initials signature below. c To the physician/facility who has referred me to Dr. essica Belz. ALL MEDIA USE Initial POLICY I hereby authorize, Dr. PAYMENT Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I understand that copies All professional services rendered to the patient. ecessary forms may be of these photographs may be used are for charged professional medical purposes deemed appropriate, including, but not limited completed to help expedite insurance payments. owever, the atient is responsible for all to: any print or broadcast media, patient education, medical education, surgical planning, office photo albums, internet, fees, regardless of insurance coverage. Pa
ent is e media, e te lay publication en ser i es are ren
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f 25. also grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary Initial INSURANCE aA
ASSIGNMENT ENE
payment or any other consideration s UTHORI
a result of ATION the use AoND f these images and Othat these ITS photographs will use discretion and be as confidential as I pauthorize release of any information concerning my or my child’s healthcare, advice and ossible. treatment for the purpose of evaluating and administering claims for insurance benefits. I also MEDICAL USE authorize ONLY payment of Insurance benefits otherwise payable to me, directly to the doctor. I I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for understand that I am financially responsible for any amount not covered by my insurance. I the purpose of medical also understand that Dr. Belz may or m
ay surgical not participate with mwith y current insurance company carrier. if care and to request authorization for procedures my insurance applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs I ere
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t case, at I afor e the rea use t is r r it as testing, rea t credentialing e an t at Iand/or ull certifying or other imaging records created in my in examination, un
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purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. Date: Patient Signature Patient’s Signature: Date 255 E
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X 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 PatientName:
PATIENTPHOTOGRAPHCONSENT
Photographsareconsideredtobeanintegralpartofyourplasticsurgicalcare.Photographsarerequiredandnearly
always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed
warranted. This is a generally accepted practice amongst plastic surgeons. Photographs are useful as a patient
educationaltool,areacriticalpartofsurgicalplanning,andareameanstoaccuratelyassessresults.
All photographs will be taken with as much discretion as possible. Care will be taken to assure they are as least
identifiableaspossible.Sincethephotoswillconcentrateontheareaofconcern,fewwillincludetheface.Yourname
will not be in the photograph. Your name will accompany the photos in storage. If the procedure includes the face,
there will be NO ability to make the photos completely anonymous. Unique identifying, non-removable, body
adornmentsuchastattoosorpiercingsmayalsoprecludeanonymity.
Photographsmayberequestedbyinsurancecompaniesorothersinvolvedinyourcare.Theymaybesentthroughthe
mail,viatheInternetorfaxmachine.
Exceptinanemergency,ifapatientrefusestoconsentforphotographs,Dr.Belzmaychoosenottoproceedwiththe
procedure.
Pleaseindicatewhichphotographconsentyouagreeto,byplacingyourinitialswhereindicatedandprovidingyourfull
signaturebelow.
ALLMEDIAUSE
Iherebyauthorize,Dr.Belzand/orherassistantstotake,utilize,andstorephotographsofmyself.Iunderstandthat
copies of these photographs may be used for professional medical purposes deemed appropriate, including, but not
limitedto:anyprintorbroadcastmedia,patienteducation,medicaleducation,surgicalplanning,officephotoalbums,
internet, practice website, advertising media, commercial media, lay publication or during lectures to medical or lay
groups.Ialsoherebygrantpermissionfortheuseofanyofmymedicalrecordsincludingillustrations,photographsor
otherimagingrecordscreatedinmycase,fortheuseinexamination,testing,credentialingand/orcertifyingpurposes
by The American Board of Plastic Surgery, Inc. I understand that I will not be entitled to monetary payment or any
other consideration as a result of the use of these images and that these photographs will use discretion and be as
confidentialaspossible.
MEDICALUSEONLY
I hereby authorize, Dr. Belz and/or her assistants to take, utilize, and store photographs of myself, solely for the
purposeofmedicalcareandtorequestauthorizationforsurgicalprocedureswithmyinsurancecompanyifapplicable.
Ialsoherebygrantpermissionfortheuseofanyofmymedicalrecordsincludingillustrations,photographsorother
imagingrecordscreatedinmycase,fortheuseinexamination,testing,credentialingand/orcertifyingpurposesbyThe
American Board of Plastic Surgery, Inc. I understand that I will not be entitled to monetary payment or any other
considerationasaresultoftheuseoftheseimagesandthatthesephotographswillusediscretionandbeasconfidential
aspossible.
PatientSignature:
WitnessSignature:
Date
255E.SonterraBlvd.,Suite201SanAntonio,TX 78258 | P210.654.9900| F210.654.6190
07/16
PATIENT PHOTOGRAPH CONSENT Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed warranted. This is a generally accepted practice amongst plastic surgeons. Photographs are useful as a patient OF PRIVACY
educational tool, are a critical part of sNOTICE
urgical planning, and are a mPRACTICES
eans to accurately assess results. NOTICE
HOW
ABOUT
MAYthey BEare USED
All THIS
photographs will DESCRIBES
be taken with as much MEDICAL
discretion as INFORMATION
possible. Care will be taken YOU
to assure as least AND
DISCLOSED
AND
HOW
YOU
CAN
GET
ACCESS
TO
THIS
INFORMATION.
identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name PLEASE
REVIEW
CAREFULLY
AND
COMPLETELY.
will not be in the photograph. Your name will IT
accompany the photos in storage. If the procedure includes the face, there will be NO ability to make the photos completely anonymous. Unique identifying, non-­‐removable, body The Health sInsurance
Portability
and Accountability
Act of
1996 (“HIPAA”) is a federal program that requires that all
adornment uch as tattoos or piercings may also preclude anonymity. medical records and other individually identifiable health information used or disclosed by us in any form, whether
electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new
Photographs may be rand
equested by how
insurance companies or others involved in your care. They may be through the rights to understand
control
your health
information
is used.
“HIPAA”
provides
penalties
forsent covered
mail, via that
the Imisuse
nternet personal
or fax machine. entities
health information. Compliance with this Act is required by April 14, 2003.
As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your
Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the health information and how we may use and disclose your health information.
procedure. We may use and disclose your medical record only for each of the following purpose: 1) treatment,
2) payment and 3) health care operations.
Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full signature below. means providing, or managing health care and related services by one or more health care
• Treatment
providers. Examples would include information pertaining to consultation, examination, surgery, and other
care. UThese
are often requested by other health care providers involved with your care or entities
medical
ALL MEDIA SE involved in your care such as hospitals and surgery centers. Insurance companies frequently request this
I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I information to determine coverage of a particular procedure, including insurance for cosmetic surgery.
understand that copies of be
these used via
for fax
professional purposes deemed appropriate, They
request
this
sentphotographs through the may mail,be and/or
or internet medical (electronic).
This information
can also
including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, include photographs. When photographs are involved, no facial features are included unless
the area
of
office photo a
lbums, i
nternet, p
ractice w
ebsite, a
dvertising m
edia, c
ommercial m
edia, l
ay p
ublication o
r d
uring lectures concern is located on the face. Mailings and/or appointment reminders sent to you or others may contain
ouror business
name,
logo grant and/orpermission doctor’s name.
We
may
you
confirming
appointment
and/or
to medical lay groups. I also for the use of send
any of my e-mails
medical records including illustrations, surgery
times,
and
request
results
of
needed
labs,
tests,
procedures,
or
medical
evaluations.
photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or
payment collection
or any other consideration as a result of the Examples
use of these images and tsending
hat these apbill
hotographs will use discretion activities
and utilization
review.
would
include
for your treatment
to an
and be as c
onfidential a
s p
ossible. insurance company or other source responsible for your payment. Please be aware that although
payments via check or credit card by you contain no health information, they will be deposited into an
readily
by bank or card personnel as being associated with a “plastic surgeon’s office.”
account
MEDICAL USE identifiable
ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for • Health
operations
the business
aspects
runningprocedures our practice,
such
asinsurance conducting
the purpose of care
medical care and include
to request authorization for ofsurgical with my company if assessment and improvement activities, auditing functions, cost management analysis and customer
applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs service.
or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or We may also contact you and distribute de-identifiable health information by removing all references to individually
identifiable information.
any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. We may contact you to provide appointment reminders or information about treatment alternatives or health related
benefits and services that may be of benefit to you. Reminders may be in the form of a letter, postcard or voice
Patient’s ignature: other uses and
disclosures
be made
only with
Date your written message Son
your answering
machine.
Any
will
authorization. You may revoke such authorization in writing and we are required to abide by that written request,
except to the extent that we have already taken actions relying on your authorization.
255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 NOTICE OF PRIVACY PRACTICES – continued
Except as described in this Notice of Privacy Practices, this medical practice will not use or disclose
personal health information, (PHI),PATIENT including P
electronic,
that identifies
you without your written
HOTOGRAPH CONSENT authorization. Individual authorization is required for uses such as psychotherapy notes, PHI for marketing, sale
of PHI, or fundraising. This practice does not participate in any of these practices at this time.
Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always taken to and after with
any respect
procedure. Photographs also be taken during as deemed You have
theprior following
rights
to your
protectedmay health
information,
whichprocedures you can exercise
by
presenting This a written
request toaccepted the Privacy
Officer,
Dr. Jessica
Belz.
warranted. is a generally practice amongst plastic surgeons. Photographs are useful as a patient educational tool, are a critical part of surgical planning, and are a means to accurately assess results. • The right to request restrictions on certain uses and disclosures of protected health information, including
those related to family members, other relatives, close personal friends or any other person identified by
All photographs will taken much discretion as atpossible. be taken frequently
to assure they as least you. It is
ourbe policy
to with be asas discrete
as possible
all times. Care We will do, however,
need are to relay
identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name information to friends and relatives pertaining to your care, such as your course during surgery or recovery.
will not be the relay
photograph. Your will accompany the photos machine
in storage. If the procedure includes face, Wein may
information
toname a significant
other or answering
about
appointments
or billingthe issues.
If you
do not
wantto usmake to callthe a place
of employment
or home or leave
messages,
please
notify us.
there will be NO ability photos completely anonymous. Unique identifying, non-­‐removable, body adornment such as tattoos or piercings may also preclude anonymity. • The right to reasonable requests to receive confidential communication of protected health information,
from us by alternative means or at alternative locations.
Photographs may be requested by insurance companies or others involved in your care. They may be sent through the mail, •via tThe
he Internet r fax machine. right to oinspect
and copy your protected health information.
Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the • The right to amend your protected health information.
procedure. • The right to receive any accounting of disclosures of protected health information.
Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full • The right to obtain a paper copy of this notice from us on request.
signature below. • The right to be notified of any breach of unsecured protected health information, as required by law.
ALL MEDIA USE reserve
the rightDr. to change
the terms
of our Notice
Privacy
Practices
and
to make
new noticeof provisions
I We
hereby authorize, Belz and/or her assistants to of
take, develop, utilize, and store the
photographs myself. I effective
of
all
protected
information
that
we
maintain.
We
will
post
and
you
may
request
a
written
copy
of
a revised
understand that copies of these photographs may be used for professional medical purposes deemed appropriate, Notice
of
Privacy
Policy
from
this
office.
including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures You have recourse if you feel that your privacy protections have been violated. You have a right to file a formal
to medical with
or lay I with
also the
grant permission the and
use of any of my medical records illustrations, complaint
ourgroups. office or
Department
of for Health
Human
Services,
Office
of Civilincluding Rights, about
photographs imaging records created in my case, of
for the use in We
examination, testing, credentialing violations of or theother provisions
of the
policies
and procedures
our
office.
will not retaliate
you
for filing a and/or complaint.purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary certifying payment or any other consideration as a result of the use of these images and that these photographs will use discretion be as confidential as possible. and MEDICAL USE ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for the purpose of medical care and to request authorization for surgical procedures with my insurance company if applicable. I also hereby grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. Patient’s Signature: Date 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 PATIENT PHOTOGRAPH CONSENT Photographs are considered to be an integral part of your plastic surgical care. Photographs are required and nearly always taken prior to and after any procedure. Photographs may also be taken during procedures as deemed NOTICE
OFamongst PRIVACY
PRACTICES
warranted. This is a generally accepted practice plastic surgeons. Photographs are useful as a patient ACKNOWLEDGEMENT
AND
CONSENT
FORM
educational tool, are a critical part of surgical planning, and are a means to accurately assess results. I understand
that
the with Health
Portability
and Accountability
Act ofto 1996
(“HIPAA”),
I have
All photographs will under
be taken as Insurance
much discretion as possible. Care will be taken assure they are as least certain rights to privacy regarding my protected health information. I understand that this information can
identifiable as possible. Since the photos will concentrate on the area of concern, few will include the face. Your name be and will be used to:
will not be in the photograph. Your name will accompany the photos in storage. If the procedure includes the face, there will be NO ability to make the photos completely anonymous. Unique identifying, non-­‐removable, body • Conduct, plan and direct my treatment and follow up among the various health care providers
adornment such as tattoos or piercings may also preclude anonymity. who may be involved in that treatment directly or indirectly.
• Obtain payment from third party payers.
Photographs may be requested by insurance companies or others involved in your care. They may be sent through the • Conduct normal healthcare operations such as quality assessments and physician certifications.
mail, via the Internet or fax machine. I have received and/or read and understand your Notice of Privacy Practices containing a more complete
Except in an emergency, if a patient refuses to consent for photographs, Dr. Belz may choose not to proceed with the description of the uses and disclosures of my health information. I understand that this organization has
procedure. the right to change the Notice of Privacy Practices from time to time and that I may contact this
organization at any time to obtain a current copy of the Notice of Privacy Practices.
Please indicate which photograph consent you agree to, by placing your initials where indicated and providing your full I understand
that I may request in writing that you restrict how my private information is used or disclosed
signature below. to carry out treatment, payment, or health care operations. I also understand you are not required to
requested
abide
by
Amy
LL M
EDIA USE restrictions, but if you agree then you are bound to abide by such restrictions.
I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself. I I understand
that
I may
this consent
in be writing
any
time, except
to the
extent deemed that youappropriate, have
understand that copies of revoke
these photographs may used at
for professional medical purposes taken
action
relying
on
this
consent.
including, but not limited to: any print or broadcast media, patient education, medical education, surgical planning, office photo albums, internet, practice website, advertising media, commercial media, lay publication or during lectures Patient name:
to medical or lay groups. I also grant permission for the use of any of my medical records including illustrations, photographs or other imaging records created in my case, for the use in examination, testing, credentialing and/or Relationship to patient:
certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or any other consideration as a result of the use of these images and that these photographs will use discretion Patient signature:
and be as confidential as possible. MEDICAL USE ONLY I hereby authorize, Dr. Belz and/or her assistants to take, develop, utilize, and store photographs of myself, solely for OFFICE USE ONLY
the purpose of care and to request authorization for surgical and
procedures with I attempted
to medical obtain the
patient’s
signature
in acknowledgement
consent
on my thisinsurance Notice ofcompany Privacy if applicable. also hereby grant permission for the uto
se do
of aso
ny o
f mdocumented
y medical records including illustrations, photographs Practices IAcknowledgment,
but was unable
as
below:
or other imaging records created in my case, for the use in examination, testing, credentialing and/or certifying purposes by The American Board of Plastic Surgery. I understand that I will not be entitled to monetary payment or Date: _____________ Initials: ________________ Reason:
any other consideration as a result of the use of these images and that these photographs will use discretion and be as confidential as possible. Patient’s Signature: Date 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190 255 E. Sonterra B lvd., Suite 201 San A ntonio, TX 78258 | P 210.654.9900 | F 210.654.6190