Patient Medical Information
Employer Information
Emergency Contact Info
Areas of Interest
Areas of Interest
Breast Procedures (mark all that apply)
Body Procedures (mark all that apply)
Medical Records Release, Assignment of Benefits, Patient Payment & No Show Policies
Medical Records Release, Assignment of Benefits, Patient Payment & No Show Policies
I hereby authorize Sovereign Plastic Surgery, PLLC (SPS) to furnish my medical information to insurance carriers, referring physicians and/or any persons I designate. I give permission for any of my medical records, x-rays, or other hospital test and/or any additional information contained in my medical records to be sent to SPS via mail or fax. I give my permission for the release of any HIV information. I also assign SPS all payments for medical services rendered to myself or my dependent(s). I understand that I am responsible for all co-pays and/or balances not covered by my insurance carrier and that all payments are to be rendered at time of service. A twenty-four hour prior notice of appointment is required in order to avoid a $30.00 "no show" fee.
There will be a pre-paid $25.00 fee for all additional forms that need to be filled out above and beyond our normally generated insurance claims (i.e. employer forms, Aflac, FMLA, etc.).