Patient Forms

We look forward to meeting you when you come to our office for your first visit. In order to expedite this process for both of us, please take a few minutes to complete these online forms. There are a total of 2 forms:

• New Patient Intake Form
• HIPAA Consent Form & Cancellation Policy

This website will walk you through each form. If you have any questions, or need help, just give us a call at the phone number listed above, and we will be happy to assist you through the process.

Upon successful completion of the forms, your information will be sent to us, and one of our staff members will review your information and will contact you if we are missing anything or need any additional information.

We look forward to meeting you soon!

* Required Fields

Please provide us the NAME of the substance you are taking, the DOSAGE (how much) and the FREQUENCY (how often) you are taking them.

PAST MEDICAL HISTORY:

Authorization to Release Information: I authorize Dr. Arnold S. Breitbart to release any information necessary, acquired in the course of my treatment, to process insurance claims.

Authorization to Pay Benefits Directly: I authorize my insurance company to pay Dr. Arnold S. Breitbart directly for medical service rendered. I understand that I will be responsible for non-covered charges, balances after insurance company benefits, deductibles and co-payments.

HIPAA Consent Form
As a result of the Health Insurance Portability and Accountability Act (HIPAA), enforced by the US Department of Health and Human Services office of Civil Rights, we are not permitted to release patient information except as stated in the Notice of Privacy Practices, or in accordance with your wishes as stated below.

This waiver authorizes Dr. Breitbart to send/give my medical information as noted:

* Required Fields

In regards to cosmetic surgery scheduling, this requires careful planning and coordination between our staff, operating room, as well as your anesthesiologist, if applicable.

Our office requires a $500 deposit when booking the surgery. A refund will only be given in the event that there is a MEDICAL CLEARANCE ISSUE and a letter by your physician is sent to our office. This deposit is subtracted from the final payment that will be due TWO weeks prior to surgery.

Thank you for your cooperation and understanding in this matter, Arnold S. Breitbart, M.D., FACS

*If person signing is not the patient, please print your name and relationship to patient*