New Patient Packet

HAVE YOU HAD OR DO YOU STILL HAVE :

• I understand that Dr. Sanders and his staff comply with all HIPAA guidelines. At my request, any staff member will provide me with a copy of these.
• I authorize staff to leave messages on my cell phone or any other number that I designate.
• I give authorization for Dr. Sanders or any members of his staff to communicate via text message 
• I, the patient or responsible parties, authorize the release of medical information to process medical claims.
• I also authorize my insurance company to pay benefits directly to George H. Sanders, M.D., APC.
• I authorize Dr. Sanders to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
• I understand that Encino Surgicenter is co-owned by George H. Sanders, MD, and Stephen D. Bresnick, MD.
• I understand that any cosmetic procedure I have with Dr. Sanders requires a $1,000 scheduling deposit which is refundable up to 3 weeks before my agreed-upon surgery date.
• I hereby permit George H Sanders, MD, and his staff to take photographs of me with the understanding that such photographs are for confidential clinical records and that all photographs remain the property of the doctor.
  
  The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

HIPAA ACKNOWLEDGEMENT

Please be aware that this is a secure email network under HIPAA guidelines. Do not submit any personal or private information unless you are authorized and have voluntarily consented to do so. We are not liable for any HIPAA violations. Understand that if you email us, you are agreeing to the use of this secure method and understand that all replies will be sent by standard (unsecured) email, which you are hereby authorizing. By checking this box you hereby agree to hold Dr. George Sanders, including its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties.