Policies, Consents and Processes
Please read our policies carefully and completely. In scheduling and accepting our services, you agree in full to the policies, consents and processes explained below.
Consent to Access and Use Personal Health Information
I hereby give my consent to Northwestern Specialists in Plastic Surgery, SC to use or disclose, for purpose of carrying out treatment, payment, or health care operations, all medical information contained in the patient records.
I acknowledge receipt of the physician’s Notice of Privacy Practices: The Notice of Privacy Practice provides detailed information about how the practice may be use and disclose my confidential information.
I understand that the physician has reserved a right to change his or her privacy practices that are described in the notice. I also understand that a copy of any revised notice will be provided to me or made available from the office.
I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be able to revoke this consent in cases where the physician has already relied on it to use or disclose my health information. Written revocation of consent must be sent to the physician’s office. The patient acknowledges that this practice is using an electronic health record information system (the “EHR System”), in coordination with Northwestern Memorial HealthCare, which is the parent organization for Northwestern Memorial Hospital (NMH) and Northwestern Lake Forest Hospital (NLFH). The collection and use of all information through the EHR System is primarily for the purpose of treatment of patients by this medical practice, NMH, NLFH, and other medical practices of physicians on staff at either hospital who have a treatment relationship with the patient and provide services in a clinically integrated care setting. All information collected through the EHR System may also be shared with, and used by, NMH, NLFH and certain other hospitals, academic institutions, and health care providers that perform medical or research activities in conjunction with NMH and NLFH (including but not limited to, Northwestern University, the Feinberg School of Medicine, Children’s Memorial Hospital, and the Rehabilitation Institute of Chicago) for the following health-related activities, including without limitation: (a) conducting peer review; (b) promoting quality assurance; (c) mortality and morbidity analysis; (d) conducting utilization review; (e) evaluating and improving the quality _of care; (f) promoting and maintaining professional standards; (g) examining costs and maintaining cost control; (h) conducting medical audits; (i) assisting the medical staff membership and credentialing process; (j) performing data quality management; (k) improving the efficiency and effectiveness of healthcare; (I) conducting research in a manner that complies with applicable law; (m) copying data from the EHR System and any related database and incorporating it into a data warehouse maintained by Northwestern University which may be accessed for any of the activities described above or in the Practice Privacy Notice. The patient further acknowledges that the information in the EHR System will contain information regarding treatment for mental health and developmental disabilities, HIV, AIDS, substance abuse, and genetic testing and counseling, and consents to the use and disclosure of such information for treatment, payment purposes, and those activities described above and in the Practice Privacy Notice as such consent may be required by state law.
Consent to Telehealth
I understand that NSPS, Inc.’s affiliated healthcare providers (“healthcare provider”) treat patients via telehealth, and I wish to be treated via telehealth. I understand that my telehealth treatment may involve all of the following (collectively “telehealth visit”):
I understand that NSPS gathers, store and transmit medical records, photo images, personal health information, or other data between me as the patient and healthcare providers and among healthcare providers and entities; Interactions between me and a healthcare provider via audio, video, and/or data communications (including store and forward technology); and Use of output data from medical devices, sound and video files.
I understand there are potential risks to a telehealth visit, including interruptions, unauthorized access which could disclose my health information, and technical difficulties. I understand that my healthcare provider or I can discontinue the treatment via telehealth visit if it is felt that the situation warrants.
I understand that my health information as part of the telehealth visit may be shared with other individuals or entities for technological and billing purposes and any information collected by my healthcare provider as part of this telehealth visit will be used for analyzing my health, possible treatments, to conduct follow-up activities with me, including to offer other products and services to me.
I understand that my care at NSPS is limited to the diagnosis and treatment skin aging and related disorders effecting cosmetic appearance and not for the diagnosis or treatment of any other medical or dermatological conditions, including skin cancer. I understand that the Website is not a substitute for the in-person treatment or advice of my local dermatologist, primary care physician, or any other qualified healthcare professional. I understand that I should never delay seeking advice from my local dermatologist, primary care physician, or any other health professionals if advised to do so by my NSPS healthcare provider, or if I have any concerns.
I understand that NSPS undertakes no obligation to review the inactive ingredients and or the base ingredients in any product that is recommended or sold to me, including, without limitation, to ascertain that I am not allergic to such inactive or base ingredients. I further understand that it is solely my responsibility to review those ingredients.
I understand that if I have an emergency health issue of any nature, I should call my local emergency medical number or take such other action as I deem necessary.
I understand that I have the right to request that the Medical Record established with NSPS be sent to my primary healthcare provider. I may request this by contacting email@example.com.
Possible Benefits of Telemedicine
Can be easier and more efficient for you to access medical care and treatment.
You can obtain medical care and treatment at times that are convenient for you.
You can interact with providers without the necessity of an in-office appointment.
Possible Risks of Telemedicine
Information transmitted to your provider(s) may not be sufficient to allow for appropriate medical decision making by the provider(s).
The inability of your provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
Your provider may not able to provide medical treatment for your particular condition via telemedicine and you may be required to seek alternative care.
Delays in medical evaluation/treatment could occur due to failures of the technology.
Security protocols or safeguards could fail causing a breach of privacy.
Given regulatory requirements in certain jurisdictions, your provider(s) treatment options, especially pertaining to certain prescriptions may be limited.
By continuing, I accept this Consent to Telehealth Treatment and I represent:
I have read or had this form read and/or had this form explained to me. That I fully understand its contents, including the risks and benefits of the telehealth service provided through NSPS.
I give my informed consent to the use of telemedicine by providers affiliated with NSPS.
I understand that the delivery of healthcare services via telemedicine is an evolving field and that the use of telemedicine in my medical care and treatment may include uses of technology not specifically described in this consent.
I understand that while the use of telemedicine may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed.
My condition may not be cured or improved, and in some cases, may get worse.
I understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telemedicine, and that I may need to seek medical care and treatment in-person or from an alternative source.
I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telemedicine services.
I understand that I have access to all of my health and wellness information pertaining to the telemedicine services in accordance with applicable laws and regulations.
I understand that I can withhold or withdraw this consent at any time by emailing NSPS with such instruction. Otherwise, this consent will be considered renewed upon each new telemedicine consultation with “Providers”.
I agree and authorize my health care provider to share information regarding the telemedicine exam with other individuals for treatment, payment and health care operations purposes.
I agree and authorize my health care provider to release information regarding the telemedicine exam to NSPS and their affiliates.
24 Hour Cancellation Policy
It is our policy to require a 24 hour notice of cancellation for a scheduled appointment. In the event that you must cancel your appointment with less than a 24 hour notice, we will assess a cancellation fee of $100.00. Same day cancellations and No-Shows will be assessed $100.00 as well.
By scheduling our services, you are agreeing to our cancellation policy and to the cancellation fee for less than 24 hours notice or “no show.”
Consent to Photography
I consent to photography that will be taken before, during, and after my surgery. The photographs and/or videography taken will become property of Northwestern Specialists in Plastic Surgery (NSPS) and may be published in Scientific Journals and/or shown for scientific/ educational reasons, and may be used for educational purposes on the NSPS website and social media networks. In addition, photos (and chart material) may be used by the American Board of Plastic Surgery or credentialing purposes. This photo consent expires January 1, 2099.
Consent to Use Email and SMS Text for Communication
Although convenient, email and SMS texting are not secure ways to discuss confidential or personal health information. If we email you, we our message may be generic and not specific to you or any other individual patient. If you ask us a medical question directly over email or text, you are accepting that our discussion is not secure, private and subject to cyber hacking.
I understand that I am option for an elective treatment/procedure/surgery that is not urgent and may not be medically necessary.
I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the treating providers at Northwestern Specialists in Plastic Surgery and the Med Spa and all of the staff are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of this virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this elective treatment/procedure/surgery. I hereby acknowledge and assume the risk of becoming infected with COVD-19 through this elective treatment/procedure/surgery, and I give my permission for the treating providers and staff of NSPS and the Med Spa to proceed with the same.
I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that, if I have COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment/procedure/surgery can lead to a higher chance of complication and death.
I understand that possible exposure to COVID-19 before/during/after my treatment/procedure/surgery may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the treatment/procedure/surgery itself.
I have been given the option to defer my treatment/procedure/surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired treatment/procedure/surgery.
I understand the explanation and have no more questions and consent to the procedure.
I attest that:
-I am not experiencing any symptom of illness such as cough, shortness of breath or difficulty breathing, fever, chills, body aches, sore throat, or new loss of taste or smell.
-I have not traveled internationally or to quarantined states within the last 14 days.
-I have not traveled to a highly impacted area within the United States of America in the last 14 days.
-As far as I am aware, I have not been exposed to someone with a suspected and/or confirmed case of COVID-19.
-I have not been diagnosed with COVID-19 and not yet cleared as non-contagious by state or local public health authorities.
-I am following all CDC recommended guidelines, such as wearing a mask in public, as much as possible to limit my exposure to COVID-19.