Financial Agreement
By signing this agreement, I acknowledge that I am responsible for the full charges for all services provided, even those not covered by my insurance. I understand that all fees are to be paid upon request and are to be remitted to Optimal Weight Loss and Surgery Consultants. Furthermore, I acknowledge that I will be held accountable for any attorney or collection fees incurred if my account becomes overdue. Patients with an overdue balance of 30 days must settle their account before scheduling their next appointment.
Appointment Cancelation Policy
To maintain the efficiency of our practice and ensure optimal care for all patients, it is necessary that appointments are either kept or canceled with sufficient notice. A fee of $50 will be charged for missed appointments or late cancellations made less than 24 hours before the scheduled appointment. This policy is in place to respect the time and resources of both the healthcare provider and other patients, while also prioritizing timely and appropriate care for all individuals.
Smoking Cessation (if getting weight loss surgery)
I understand that if undergoing weight loss surgery, quitting smoking is essential. Smoking or using nicotine products significantly raises the risk of post-surgical complications, such as post-operative gastric ulcers. As a result, your physician mandates that all patients must stop using nicotine products before any bariatric surgeries. A nicotine blood test will be necessary before your bariatric surgery, as required by your physician and potentially by your insurance provider.
Consent to Treat
I authorize Optimal Weight Loss and Surgery Consultants and its healthcare providers, nurse practitioners, and staff to perform medical evaluations and administer essential medical treatments as deemed appropriate by their professional expertise. I consent to undergoing procedures such as diagnostic tests, medical treatments, or surgeries. This permission will remain valid until revoked in writing. I understand that medical care will not be provided if this consent form is not signed.
Authorization to release information
I hereby grant authorization to Optimal Weight Loss and Surgery Consultants to disclose or obtain medical records and insurance information related to my treatment from any hospitals, insurance companies, physicians involved in my medical care, and employers if my coverage falls under a group insurance plan. A copy of this authorization shall be deemed as valid and enforceable as the original document.
Communication Authorization for Protected Health Information (PHI)
I give permission to Optimal Weight Loss and Surgery Consultants to share my Protected Health Information (PHI) through various means such as home/cell/work phone and/or email.
I also authorize Optimal Weight Loss and Surgery Consultants and any affiliated agencies to openly disclose my health information to the individuals listed below. I acknowledge that this authorization can only be revoked in writing. This section must be filled out in order to discuss treatment with anyone besides yourself, including your spouse, children, parents, etc.