Consent to Treatment and Related Authorizations

Consent to Treatment and Related Authorizations

CONSENT TO TREATMENT:
The undersigned authorizes Dr. Oppenheimer and staff (the “Practice”) to provide examinations, treatments, or procedures that, in their professional judgment, are medically necessary and appropriate for the above-named patient. I understand that there is no guarantee of satisfaction, outcome, or results with any medical consultation, treatment, or intervention.

CONSENT FOR PELVIC EXAMINATION:
I expressly consent to pelvic examinations, indwelling (Foley) catheter placement, and/or surgical skin preparation of my genitalia by Dr. Oppenheimer and/or associated providers, extenders, and assistants, only as medically necessary during the course of my care, and performed in accordance with accepted medical standards, with appropriate patient privacy, dignity, and professional supervision.

RELEASE OF RECORDS AND COMMUNICATION AUTHORIZATION:
I authorize the Practice to furnish affiliated entities involved in my care, billing, operations, or legal compliance with information concerning my treatment as necessary to complete care or as required by law, including copies of my medical records. I further authorize the Practice to provide relevant medical information from my records to other physicians or medical facilities involved in my continued care. I also authorize the Practice to communicate with me and my designated Emergency Contact regarding my care via phone, text message, email, and in person.

PAYMENT AGREEMENT:
I understand that I am financially responsible for all charges for treatment received, regardless of insurance coverage. I understand that the Practice does not guarantee payment by insurance and cannot accept responsibility for disputed, delayed, or unpaid claims. The Practice reserves the right to decline further services for non-payment. Patient accounts are due four (4) weeks prior to surgery or at the time of treatment for aesthetic services. I assign insurance benefits payable to the physician or organization furnishing services. Patients who confirm office-based appointments and fail to appear (“no-show”) may forfeit associated costs. Patients who have paid in full for surgery and cancel are subject to the Practice’s cancellation fee policy.

ATTORNEYS’ FEES:
In any legal dispute arising out of or relating to this Agreement or the patient’s care, the prevailing party shall be entitled to recover reasonable attorneys’ fees and costs, as permitted by law.

CONSULTATION FEE:
$200–$300

PHOTOGRAPHIC AND VIDEO AUTHORIZATION:
I consent to the taking of photographs and/or video recordings by the Practice in connection with my medical care. Such photographs and videos shall become the property of the Practice and may be used for medical records, documentation, and preoperative or postoperative planning. Use of photographs or videos for educational, marketing, website, or social media purposes requires separate and express consent.

ACKNOWLEDGMENTS AND WAIVERS:
I understand that photographs and videos are the property of the Practice and will not be returned. I waive any right to inspect or approve photographs or videos prior to authorized use. I waive any right to payment, royalties, or other compensation arising from authorized use. I acknowledge that photographs and videos may constitute Protected Health Information under HIPAA. I understand that once photographs or videos are shared publicly with my authorization, the Practice may have limited or no ability to remove them and I authorize continued use under those circumstances. I acknowledge that I have the right to receive a copy of this authorization upon request.

TERM AND REVOCATION:
This authorization shall remain in effect for twenty-five (25) years, consistent with medical record retention and documentation requirements, unless revoked earlier. I may revoke this authorization at any time by providing written notice to the Practice. Any use made prior to revocation remains authorized.

PRIVACY AND ONLINE COMMUNICATIONS:
I understand that information disclosed under this authorization may be protected by state law and/or the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). I release the Practice from claims related to authorized uses of photographs and videos. I acknowledge that the Practice may respond to online reviews I post in a general and non-identifying manner that does not disclose protected health information.

DIGITAL COMMUNICATION AUTHORIZATION:
I authorize the Practice to communicate with me via digital means, including email, text messaging, and direct messaging on social media platforms. I understand that electronic communications may involve risks of unauthorized access during transmission or after delivery to the address or number I have provided. The Practice will take reasonable steps to protect communications prior to transmission and will use the minimum necessary protected health information when communicating with me.

MEDICAL HISTORY REPRESENTATIONS:
I understand that the Practice relies on the accuracy and completeness of the medical history I provide. I will not hold the Practice responsible for errors or omissions in the medical information I disclose.

ARBITRATION AGREEMENT:
THE PATIENT, OPPENHEIMER PLASTIC SURGERY LLC, THE SODO SURGERY CENTER LLC, AND ANY AFFILIATED PROVIDERS AND STAFF (“PARTIES”) IRREVOCABLY AGREE TO RESOLVE BY DISCUSSION IN GOOD FAITH ANY DISPUTE (“DISPUTE”) ARISING OUT OF OR RESULTING FROM A CONSULTATION, TREATMENT, PROCEDURE, OR SURGERY, INCLUDING BUT NOT LIMITED TO QUESTIONS OF QUALITY OR STANDARD OF CARE, LIABILITY, ARBITRABILITY, AND THE EXISTENCE, VALIDITY, AND SCOPE OF THIS AGREEMENT. IF THE PARTIES ARE UNABLE TO RESOLVE THE DISPUTE WITHIN SIXTY (60) DAYS AFTER WRITTEN NOTICE, THE DISPUTE SHALL BE SUBMITTED TO FINAL AND BINDING ARBITRATION BEFORE A SINGLE ARBITRATOR SELECTED BY THE PARTIES IN ORANGE COUNTY, FLORIDA. THE ARBITRATION SHALL BE GOVERNED BY THE REVISED FLORIDA ARBITRATION CODE AND ADMINISTERED BY THE AMERICAN ARBITRATION ASSOCIATION IN ACCORDANCE WITH ITS COMMERCIAL ARBITRATION RULES. JUDGMENT ON THE AWARD MAY BE ENTERED IN ANY COURT HAVING JURISDICTION. IF A COURT DETERMINES THAT ARBITRATION IS NOT BINDING OR PERMITS LITIGATION TO PROCEED, THE PARTIES WAIVE ANY RIGHT TO A TRIAL BY JURY.

NOTICE OF PRIVACY PRACTICES:
By my signature below, I acknowledge that I have reviewed the Oppenheimer Plastic Surgery Notice of Privacy Practices.

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