monalisa touch vaginal fee acknowledgment · monalisa touch vaginal fee acknowledgment ......

WOMEN’S WELLNESS INSTITUTE OF DALLASWWW.WOMENSWELLNESSINSTITUTE.COM


WOMEN’SWELLNESSINSTITUTE

OF DALLAS

WWW.WOMENSWELLNESSINSTITUTE.COM


OF DALLAS


WWW.WOMENSWELLNESSINSTITUTE.COM WWW.WOMENSWELLNESSINSTITUTE.COM

WOMEN’S WELLNESS INSTITUTE OF DALLASWESLEY ANNE BRADY, M.D.

MEDICAL DIRECTOR

F 214.442.0056P 214.442.0055 TOLL FREE 866.505.99439101 N CENTRAL EXPRESSWAY SUITE 550 DALLAS TEXAS 75231WWW.WOMENSWELLNESSINSTITUTE.COM

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MONALISA TOUCH VAGINAL FEE ACKNOWLEDGMENT

Preventative medicine and laser therapy are a unique practice and are considered a form of alternative medicine. Even though the physicians and nurses are board certified as Medical Doctors and RN’s or NP’s, insurance does not recognize it as necessary medicine BUT is considered like plastic surgery (aesthetic medicine) and therefore is not covered by health insurance in most cases.

This practice is not associated with any insurance companies, which means they are not obligated to pay for our services (blood work, consultations, insertions or pellets). We require payment at time of service and, if you choose, we will provide a form to send to your insurance company and a receipt showing that you paid out of pocket. WE WILL NOT, however, communicate in any way with insurance companies.

This form and receipt are your responsibility and serve as evidence of your treatment. We will not call, write, pre-certify, or make any contact with your insurance company. Any follow up letters from your insurance to us will be thrown away. If we receive a check from your insurance company, we will not cash it, but instead return it to the sender. Likewise, we will not mail it to you. We will not respond to any letters or calls from your insurance company.

For patients who have access to Health Savings Account, you may pay for your treatment with that credit or debit card. This is the best idea for those patients who have an HSA as an option in their medical coverage.

Secondary treatment packages will receive a 50% discount. Payment in full is due at the time of the initial treatment. A 10% discount is extended to any breast cancer survivor.

We accept the following forms of payment:Master Card, Visa, Discover, American Express, Personal Checks, Cash, Care Credit and United Medical Credit.

Patient Name:

Patient Signature:

Date:

MonaLisa Touch Vaginal Treatment PackageMonaLisa Touch Vulvar Treatment Package

Mona Lisa Touch Annual MaintenanceCombination of Vaginal & Vulvar Treatment Package

.................... $3,000.00 (includes 3 treatments)

.................... $3,000.00 (includes 4 treatments)

.................... $500.00

.................... $4,500.00




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MONALISA TOUCH VAGINAL PATIENT QUESTIONNAIRE

Patient Name: _______________________________________________

Patient’s DOB: _______________________

Date: __________________________

Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Pain (0-10) ________

Vaginal burning (0-10) ________

Vaginal itching (0-10) ________ Vaginal dryness (0-10) ________

Painful urination (Dysuria) (0-10) ________

Painful sexual intercourse (Dyspareunia) (0 - 10) _____

Very happy, no hurt

Hurts just a little bit

Hurts a little more

Hurts even more

Hurts a whole lot

more

Hurts as much as you can imagine

0 2 4 6 8 10

Please indicate the level of discomfort you are experiencing for each category below (rate 0-10):

Please indicate the level of discomfort you are experiencing for each category below (rate 0-10):




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MONALISA TOUCH VAGINAL TREATMENT INFORMED CONSENT TO TREAT

I request and authorize Dr. Wesley Anne Brady to perform a procedure on me using the MonaLisa Touch laser.

Therapy using the Mona Lisa Touch laser is an appropriate treatment for vaginal symptoms due to menopause.

The CO2 laser produces small columns of damage in the soft tissue of the vaginal walls. These columns help stimulate new collagen production which helps promote mucosal revitalization and improved vaginal vascular health.

The nature and effects of the procedure, the results, as well as alternative methods of treatment have been fully explained to me by the physician or designated person and I understand them.

I have been thoroughly and completely advised regarding the end point of the procedure. I understand that the practice of medicine and surgery is not an exact science and no results have been guaranteed. I acknowledge that the operative result may not meet my expectations. I certify that no guarantees have been made by anyone regarding the procedure(s) that I have requested and authorized.

All persons in the treatment room, including myself, will wear protective eyewear to prevent eye damage.

I understand the procedure is comfortably tolerated without sedation or anesthesia, although a topical numbing cream may be offered to me to aid in the comfort of the probe insertion. The treatment takes about 5 (five) minutes to complete. There are no known associated side effects following this procedure. I should refrain from strenuous exercise and sexual activity for 2 (two) days after the procedure.

I have read and understand all information presented to me before signing this consent. I have also been given the opportunity to ask questions and understand the information provided.

Patient Signature: _________________________________________________ Date: ______________________(Patient or person authorized to consent for the patient)

Witness Signature: ________________________________________________




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MONALISA TOUCH VAGINAL PRE & POST-TREATMENT INSTRUCTIONS

It is important to follow your treatment provider’s instructions before and after treatment.

PRE-TREATMENT INSTRUCTIONS:

POST TREATMENT INSTRUCTIONS:

OTHER INSTRUCTIONS:

Patient Signature: _________________________________________________ Date: ______________________(Patient or person authorized to consent for the patient)

If you have any questions about these instructions or the procedure, please contact your physician.




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PATIENT INFORMATION FORM

( ) New Patient ( ) Update ( ) Name Change

PATIENT INFORMATION

Patient Name: ___________________________________ Date of Birth: _____________________ Age: _______

Maiden Name or Former Name: ___________________________________________________________________

Address: ___________________________________________________ Apartment Number: _________________

City: ___________________________________ State: _______________________ Zip Code: _______________

Home Phone: ( ) ___________________ Cell Phone: ( ) ____________________

Email(s): _____________________________________________________________________________________

Drivers License Number: __________________________________________

( ) Single ( ) Married ( ) Separated ( ) Divorced ( ) Widowed

Patient Employed: ( ) Yes ( ) No Occupation: _______________________________________________

Employer: ___________________________________________ Work Number: ( ) ______________________

Spouse/Parent Name: ___________________________________________________________________________

Employer: ___________________________________________ Work Number: ( ) ______________________

Emergency Contact: ________________________ Relation: _____________ Phone: ( ) _________________

How did you hear about us?( ) Web-Site(s) _______________________________________________________________________________

( ) Search Engine(s): ____ Google ____ Yahoo ____ Bing ____ Other(s) ___________________________

( ) Physician: ______________________________ ( ) Friend/Family: ________________________________

( ) Advertisement: ____ D Magazine ____ Newspaper ____ University Park Life

( ) Other(s) __________________________________________________________________________________

INSURANCE INFORMATION

Primary Insurance: _____________________________________ ( ) Private ( ) PPO/POS ( ) HMO/EPO

Name of Policy Holder: __________________________________________________________________________

Social Security Number: ___________-__________-___________ Date of Birth: ______________________

Policy ID/Subscriber Number: __________________________________ Group Number: _____________________

I authorize the release of all medical information required in the course of examination or treatment to any insurance group or carrier which I may have in support of benefi ts to which I may be entitled. I further direct that payment of my benefi ts under such insurance due for services rendered is hereby assigned to the Women’s Wellness Institute of Dallas. I further recognize and accept personal responsibility for full payment of the charges for professional services rendered to me at my request. Requests to amend information must be made in writing. Requests to access records must be made in writing. There will be a charge for any summaries of records.

Patient Signature: Date:




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PATIENT PRIVACY FORM

Patient’s Name: _____________________________________ D.O.B.: _______________________

I hereby authorize Women’s Wellness Institute of Dallas to release any information pertainingto my medical care to the following person(s):

Name ______________________________________ Relationship _________________________





( ) I do not wish to have my medical information released to anyone.

Are there phone numbers where Dr. Wesley Anne Brady or the nurse leave a message with specifi cmedical results and information?

( ) Yes

( ) No

Phone Number: (________) ____________________

Phone Number: (________) ____________________

*This information will remain in effect unless you inform us of additions/deletions.

Patient Signature: Date:

Witness Signature:




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NEW PATIENT MEDICAL HISTORY

Patient Name: _____________________________________________ Date: _____________________________

Reason for visit: ________________________________________________________________________________

PAST MEDICAL HISTORY: Please check any of the medical conditions below that you have had:

_____ Birth Defects _____ Head Aches _____ Thyroid Disease_____ Genetic Diseases _____ Asthma _____ Diabetes _____ Stroke _____ Liver Disease _____ Heart Attack _____ Stomach Ulcers _____ Seizure Disease _____ High Blood Pressure_____ Gallbladder Problems _____ Heart Disease _____ Kidney Disorders _____ Mental Disorders _____ Blood Clots _____ Breast Disease _____ Anemia _____ Other: ______________________________________________

Please explain any of the above: ___________________________________________________________________

SURGERY: Please list date, type of surgery, and any surgical complications for all procedures.

DATE TYPE OF SURGERY COMPLICATIONS

ALLERGIES: Please list the name of any medication you are allergic to and the reaction you had:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

MEDICATIONS: Please list all current medications you are taking, including vitamins and supplements.

MEDICATION DOSAGE HOW OFTEN DO YOU TAKE IT?




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GYN HISTORY:Age of fi rst menstrual period: _____________ Have you ever had a sexually transmitted infection: _________Length of menstrual fl ow in days: __________ (Herpes, Gonorrhea, Chlamydia, HIV)Amount of fl ow: Light Moderate Heavy Have you ever used birth control pills: ____________Do you have regular menstrual periods: _________ Have you ever used an IUD: _____________Have you ever had an abnormal PAP: ___________ Have you ever used Depo Provera: ______________How was it treated: __________________________

PREGNANCY HISTORY: Please list all pregnancies (full-term/pre-term pregnancies, miscarriages, abortions, etc.).

DATE FULL TERMPRE TERM

MISCARRIAGEABORTION

WEEKS PREGNANT AT

DELIVERY

SEX VAGINAL OR C-SECTION

COMPLICATIONS

SOCIAL HISTORY:Do you smoke: ___________ How many packs per day: ___________ How long have you been smoking: _______Do you drink alcohol: ______ What kind of alcohol: _________________ How much do you drink: ______________Have you ever used drugs: _________ Which drugs: __________________________________________________

FAMILY HISTORY: Do you have any blood relatives with any of the conditions listed below?_____ Colon Cancer _____ High Blood Pressure _____ Thyroid Disease_____ Uterine Cancer _____ Heart Attack _____ Stroke_____ Cervical Cancer _____ Lung Disorder _____ Kidney Disease_____ Breast Cancer _____ Endometriosis _____ Liver Disease_____ Ovarian Cancer _____ Mental Disorders _____ Diabetes_____ Osteoporosis _____ Babies with Birth Defects _____ Blood Disorders

_____ Other: __________________________________________________________________________________

SYMPTOMS: Please check any that apply._____ Recent weight loss _____ Blood in stool _____ Cold all the time_____ Recent weight gain _____ Black colored stools _____ Hot all the time_____ Fevers _____ Abdominal pain _____ Nervousness_____ Skin rash _____ Decreased appetite _____ Memory loss_____ Pelvic Pain _____ Burning with urination _____ Lumps in breast_____ Severe mood swings _____ Frequent urination _____ Depression_____ Nipple discharge _____ Blood in urine _____ Chest pain_____ Pain with intercourse _____ Leaking of urine _____ Painful periods_____ Swelling of the feet _____ Varicose veins _____ Hot fl ashes_____ Heartburn _____ Night sweats _____ Joint pain_____ Nausea _____ Seizures _____ Vomiting_____ Irregular vaginal bleeding _____ Easy bruising _____ Vaginal itching_____ Diarrhea _____ Vaginal discharge _____ Constipation _____ Excessive thirst _____ Vaginal dryness

_____ Other: __________________________________________________________________________________




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NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice is provided to briefl y summarize how we handle your health information, and provides details of our privacy policies and procedures.

How we may use and disclose your health information: We use health information about you for treatment, to get paid for treatment, for administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information may be shared by paper, mail, electronic mail, fax, or other methods. We may use or disclose your health information without your authorization for appropriate medical reasons, for any situation beyond those we will ask for your written authorization before using or disclosing your health information. If you sign an authorization to disclose information, you can later revoke it to stop any future uses and disclosures.

Your rights: In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. If you request copies, we may charge you a cost-based fee. You also have the right to request a list of certain types of disclosures of your information that we may have made. If you believe your health information is incorrect or information is missing, you have the right to request that we correct the existing information or add the missing information.

Our legal duty: We are required by law to protect the privacy of your health information, provide this notice about our privacy practices, follow the privacy practices that are described in this notice, and see to your acknowledgment of receipt of this notice. We may change our privacy policies at any time. Before we make a signifi cant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at anytime. For more information about our privacy policies, contact the person listed below.

HIPAA/HITECH notice: We are required to notify you that we use e-mail correspondence for purposes of offi ce operations, including but not limited to appointment and treatment reminders. If you wish to decline this means of communication, you must do so in writing. We discourage the use of text messaging because those messages are the property of telecommunication companies and therefore your privacy is NOT protected. Any text message you send to any member of our staff indicates that you waive your rights to privacy regarding that message as well as any and all other incidences of text messaging with any member of this offi ce’s staff.

Privacy complaints: If you are concerned that we have violated your privacy rights, our privacy policies, or if you disagree with a decision we made about access to your health information, you may contact the person listed below. You may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

If you have any questions please contact our Practice Administrator at (214) 442-0055.

Acknowledgment of receipt of Notice of Privacy Practices: Please sign and print your name and provide the date below to acknowledge that you have received this Notice of Privacy Practices.

Patient Name:

Patient Signature:

Date:




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OFFICE POLICIES

Our Philosophy

The Women’s Wellness Institute of Dallas has one principal philosophy – that feminine health, wellness and beauty emanate from within. The Institute’s goal is to educate and support a woman’s healthy inner-core by providing medical procedures, quality healthcare, supplements and wellness guidance that complement and complete overall health.

Offi ce Hours

Our normal offi ce hours are 8:00am to 4:00pm Monday, Tuesday, Thursday, Friday, and 8:30am to 3:00pm on Wednesday. A lunch hour is taken from 12:00pm to 1:00pm.

Cancellation Policy

We look forward to meeting you at your scheduled appointment. However, if you are unable to keep your appointment, we ask that you contact us as soon as possible to make other arrangements so that other patients may use this time. For those patients who do not cancel or reschedule at least 24 hours prior to the appointment, a $25.00 no-show/cancellation fee may be charged. Please be aware that insurance companies will not cover this expense.

Insurance Affi liation

Our staff will do its very best to verify your insurance coverage and benefi ts prior to your appointment, then afterwards fi le a claim directly to the plan. If the services are not covered by your health care plan or we cannot verify coverage, we will expect payment for our services prior to or at the time of your appointment.

The Women’s Wellness Institute of Dallas is a participant in many managed care programs which require members to pay a co-payment for an offi ce visit. The co-payment is expected at the time you are greeted for your visit. As these contracts are frequently reviewed and changed, we will ask to see your insurance ID card at each visit. Our offi ce verifi es your benefi ts at each appointment, so please bring the most current insurance information each time you come in. If you cannot provide current verifi able coverage, payment in full will be required prior to services rendered. If you cannot make full payment at that time, we will reschedule your visit for another day. Financing options are not available for offi ce co-payments or regular offi ce charges.

Most insurance policies stipulate a deductible or coinsurance for major procedures or surgeries which must be honored prior to your procedure. After we fi le the claim, Explanations of Benefi ts (EOBs) will be sent to our offi ce and to yourself, which will refl ect how your provider processed the claim, how they applied your deductible, and how much your coinsurance would be. If you overpaid, you can expect a prompt reimbursement from our offi ce, but if you underpaid we will expect that reimbursement promptly as well.

Please note that because of the large number of plans with which we must work and the fact that each plan is different, it is your responsibility to determine whether or not you need to obtain a referral from your primary care physician.




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Ancillary Services

Recommended treatment plans may include lab work, pathology, or imaging studies. We do our very best to determine your insurance carrier’s preferred vendor, but it is your responsibility to familiarize yourself with your policy and request the appropriate lab, pathology, or radiology center when necessary. Ancillary providers will fi le insurance and bill separately for their services.

Fees and Payment

The fees for our offi ce are based on the local usual and customary professional fees for gynecology in the Dallas area. For services not covered by insurance we accept cash, checks, and credit or debit cards including Visa, MasterCard, Discover, and American Express. Returned checks will incur a reprocessing fee for which you will be responsible.

Multiple fi nancing options are available for cosmetic procedures including no interest loans for 6 months. The qualifi cation process takes just minutes either online or by phone. Payment plans are also available extending up to 12 months. Please contact our offi ce administrator for details if this option interests you.

There will be a $25 fee for fi lling out disability documentations, work forms, attestations, letters, or other affi davit forms. A self pay fee schedule is available upon request.

Prescriptions and Refi lls

Please attempt to request new prescriptions or refi lls at your appointment time. If you need a medication refi ll between appointments, please instruct your pharmacist to fax our offi ce your refi ll request at214-442-0056. A new medication will likely require a visit with the physician. Medications will not be fi lled after hours. Please keep the offi ce upated with your current pharmacy information for the most effi cient refi ll services.

Emergency Care

Please limit after hours calls to emergencies only. If you have an emergent medical situation, call our offi ce at 214-442-0055. If the service is unable to reach the physician for you, proceed to the nearest emergency room. The physician shares call with a call group ensuring a board certifi ed OB-GYN will always be available in the event of an emergency.

Confi dentiality

Because we are HIPAA compliant, your medical information is strictly confi dential. We will not release it to anyone without your written consent.

Medical Records

The release of your private medical information is done only with your written consent. There is a charge of $25.00 for the fi rst 20 pages of medical records copies and .50 cents for each additional page thereafter. We will forward your records to another physician at no charge.




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OFFICE POLICIES – ADDENDUM

you are unable to attend an appointment. That time slot will be given to someone who is in urgent need of treatment. There will be a $25 fee assessed to those who do not allow 24 hour notice when cancelling and to those who neglect to appear for an appointment.

appointment. In the event that you are running late, please call the offi ce. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule.

a one-week notice. There will be a $25 fee for these disability forms, insurance appeals, etc.

Please allow 48 hours for all medication refi lls. I have read and received a copy of the Women’s Wellness Institute of Dallas Offi ce Policies. My signature indicates my understanding that our professional relationship is governed by these policies.

I have read and received a copy of the Women’s Wellness Institute of Dallas Offi ce Policies. My signature indicates my understanding that our professional relationship is governed by these policies.

Patient Name:

Patient Signature:

Date:

monalisa touch vaginal fee acknowledgment · monalisa touch vaginal fee acknowledgment ......

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