Plastic Surgery Patient Forms

Please complete this form to help the professionals at the Umansky Medical Center better understand your needs. The form requests contact and medical history information, and advises patients of their financial responsibility for services rendered.
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This notice discloses the obligation that all physicians in California have to inform patients that they are licensed by the Medical Board of California. Contact information for the Board is also included in this notice.
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This notice explains the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), a federal program requiring that all medical records that are used or disclosed be kept properly confidential. The document describes how patients’ medical information is used or disclosed, and how patients can obtain access to that information.
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Patients are asked to review the Notice of Privacy Practices document above and sign this Privacy Practice Acknowledgement form to confirm receipt of the Notice of Privacy Practices.
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