Email * DEMOGRAPHIC & MEDICAL HISTORY *
The patient demographic and medical history information provided is true and correct as verified by myself.
HIPAA PRIVACY NOTICE *
Contemporary Plastic Surgery is in compliance with the HIPAA Omnibus Final Rule 2013. The notice of health information privacy policies for Contemporary Plastic Surgery will have been presented for review by the patient prior to being seen. By signing below, he/she acknowledges that he/she has been presented with a copy of Vaishali B. Doolabh, MD Notice of Privacy Practices, and has had an opportunity to ask any and all questions to their satisfaction, and is signing below voluntarily.
I, authorize the following person to have access to my medical records:
This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Contemporary Plastic Surgery may provide marketing communications to patients about third-party’s products or services.
Our commitment to your privacy
Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information. We realize that these laws are complicated, but we must provide you with the following important information:
Use and disclosure of your health information in certain special circumstances
The following circumstances may require us to use or disclose your health information.
1. To public health authorities and health oversight agencies that are authorized by law to collect information.
2. In response to a court or administrative order such as in a lawsuit or similar proceeding.
3. If required to do so by a law enforcement official.
4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.
5. If you are a member of US or Foreign military forces (including veterans) and if required by the appropriate authorities.
6.To federal officials for intelligence and national security activities authorized by law.
7. To correctional institutions or law enforcement officials if you are an inmate or under custody of a law enforcement official.
8. For Worker’s Compensation and similar programs.
Your rights regarding your health information
1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. We will accommodate reasonable requests. Please know that text messages are not secure and our email is not encrypted. We cannot guarantee maintenance of your privacy rights if you use text messaging and/or email to transmit your medical information.
2. You can request a restriction in out use or disclosure of your health information for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment of your care, such as family members or friends, we are not required to agree to your requests; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when information is necessary to treat you.
3.You have the right to opt out of any research studies.
4. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Contemporary Plastic Surgery, Vaishali B. Doolabh, M.D., 7035 Southpoint Parkway South, Jacksonville, Florida 32216. All requests will be completed within 30 calendar days.
5. You may ask us to amend your health information if you believe it is incorrect or incomplete, as long as the information is kept by or for our practice. To request an amendment, you must submit your request in writing to Contemporary Plastic Surgery, Vaishali B. Doolabh, M.D., 7035 Southpoint Parkway South, Jacksonville, Florida 32216. You must provide documentation that supports your request for amendment.
6. Right to a copy of this notice. You have the right to a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a copy, please contact the receptionist at the front desk.
7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. You must submit your complaint in writing to Contemporary Plastic Surgery, Vaishali B. Doolabh, M.D., 7035 Southpoint Parkway South, Jacksonville, Florida 32216. You will not be penalized for filing a complaint.
8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses or disclosures that are not identified by this notice or permitted by applicable law.
If you have any questions regarding this notice or our health information privacy policies please contact Contemporary Plastic Surgery, Vaishali B. Doolabh, M.D., 7035 Southpoint Parkway South, Jacksonville, Florida 32216.
Contemporary Plastic Surgery is licensed and dispenses limited pharmaceuticals, such as Tretinoin Cream, 4% Hydroquinone and Latisse. These prescriptions may be filled in this office or any pharmacy.
CREDIT CARD USE *
In the event that you use a credit card and initiate a chargeback, your signature below gives Contemporary Plastic Surgery permission to transmit your medical records to your credit card issuer.
NOTICE OF EXCLUSIONS FROM INSURANCE BENEFITS, INCLUDING MEDICARE *
By signing below you, acknowledge that you understand in advance, cosmetic procedures do not meet the definition of a covered benefit and cannot be filed with your insurance carrier, including Medicare, for reimbursement. All procedures performed in this office are cosmetic and no insurance, including Medicare, will be filed by Contemporary Plastic Surgery or the patient.
APPOINTMENT CANCELLATION POLICY *
We strive to provide excellent care to you and all of our patients. In order to do so, effectively and efficiently, we have developed an appointment system that sets aside ample time for a patient. “No-shows” and late cancellations inconvenience those individuals who need access to our services in a timely manner. In an effort to reduce the number of such occurrences, we have implemented an Appointment Cancellation Policy and it is effective immediately.
Our policy is as follows:
1. We request you give our office at least 24 hour notice in the event you need to reschedule your appointment. Our phone number is 904-854-4800.
2. If you miss an appointment and do not contact us with at least a 24 hours prior notice, we will consider this a missed appointment and a $50 no-show fee with be assessed to you. This applies to late cancellations and “no-shows.”
3. If you are more than 15 minutes late for an appointment, you will have to be rescheduled. We would not have the proper amount of time to complete your appointment. You will be required to pay a $50.00 deposit to secure your next appointment. This deposit will be used towards your service for that appointment. If you do not cancel that appointment prior to 24 hours or you no show to that appointment it will be used for your cancellation fee.
4. Our office makes reminder calls for appointments. It is ultimately the patient’s responsibility to remember their scheduled appointments.
The cancellation fee must be paid prior to your next appointment.
Thank you for trusting Contemporary Plastic Surgery to care for you.
I have read and understand the Appointment Cancellation Policy and agree to the terms of this policy.
HEALTHCARE RECORDINGS *
To ensure confidentiality and privacy, any type of electronic recording with mobile devices is strictly prohibited at any location within these offices. The office does use security surveillance cameras. Recording discussions about health care via video or audio is not a substitute for listening, and breaches the confidentiality rights of other patients and employees.
You, the above named patient, agree that by signing below, your agreement or consent will be legally binding and enforceable, and the legal equivalent of your handwritten signature.