• NEW PATIENT INFORMATION

  • NIRMAL S. JAYASEELAN, M.D .. P.A.
    GENERAL AND LAPAROSCOPIC SURGERY
    11970 NORTH CENTRAL EXPRESSWAY SUITE 670
    DALLAS, TX 75243
    972.331.1111 (OFFICE)
    972.331.1112 (FAX)

    • General Information  
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    • Insurance Information  
    • Primary Insured Information (If Different From Patient)  
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    • EMERGENCY CONTACT  
    • RESPONSIBILITY PARTY STATEMENT: AS THE RESPONSIBLE PARTY, I AGREE THAT ALL CHARGES THAT ARE NOT DIRECTLY PAID BY MY INSURANCE WILL BE MY RESPONSIBILITY.

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    • MEDICAL HISTORY QUESTIONNAIRE  
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    • SOCIAL HISTORY  
    • OBESITY RELATED MEDICAL HISTORY  
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    • ACKNOWLEDGEMENT OF PRACTICE POLICIES AND PROCEDURES - GENERAL SURGERY  
    • 1. WE WILL COLLECT YOUR OFFICE SPECIALIST CO PAY + CO INSURANCE IF APPLIES AT EACH VISIT. YOUR COPAYMENT/ CONSULTATION FEE CAN TAKE UP TO THREE WEEKS TO CLEAR FROM YOUR BANK.

      2. UNLESS TOLD OTHERWISE BY THE DOCTOR, YOU ARE REQUIRED, TO FOLLOW A CERTAIN PRE-SURGERY DIET WHICH CONSISTS OF LIQUIDS FOR ONE WEEK PRIOR TO SURGERY. IF YOU DO NOT ADHERE TO THE LIQUID DIET YOUR SURGERY WILL CANCELED BY DR. JAYASEELAN.

      3. YOU WILL BE REQUIRED TO PAY YOUR FEES DEDUCTIBLE, CO-INSURANCE ONE WEEK PRIOR TO SURGERY. THIS AMOUNT VARIES FROM PERSON TO PERSON, DEPENDING ON THE INDIVIDUAL CO-PAYMENT, CO-INSURANCE, DEDUCTIBLE AND HEALTH PLAN. A CANCELLATION FEE WILL BE CHARGED TO YOU IF YOU FAIL TO CANCEL YOUR SURGERY WITHIN 48 HOURS PERIOD.

      4. YOU AND YOUR HEALTH INFORMATION ARE PROTECTED BY HIPPA REGULATIONS. WE WILL NOT GIVE ANYONE INFORMATION ABOUT YOU, UNLESS WE HAVE WRITTEN AN AUTHORITY TO DO SO. THE ONLY EXCEPTION IS GIVING INFORMATION TO YOUR INSURANCE COMPANIES AND DISABILITY COMPANIES. IF YOU NEED MORE INFORMATION ON HIPPA LAWS PLEASE ASK RECEPTIONIST.

      5. PLEASE BE RESPONSIBLE ABOUT THE INSURANCE INFORMATION YOU PROVIDE TO OUR OFFICE. IF YOUR INSURANCE COMPANY, POLICY, AND OR JOB CHANGES, IT IS YOUR RESPONSIBILITY TO NOTIFY OUR OFFICE. IF YOUR BENEFITS HAVE CHANGED AND YOU DID NOT NOTIFY OUR OFFICE IN WRITING, YOU WILL INCUR ALL MEDICAL COSTS. THIS INCLUDES SURGEON’S FEES, ANESTHESIA FEES, FACILITY FEES, ATTORNEY’S FEES AND ANY COSTS INCLUDED IN RECOVERING THE AMOUNTS DUE TO ALL THAT HAVE PROVIDED CARE FOR YOU.

      * THIS IS ONLY AN ESTIMATE UNTIL YOU ARE SEEN IN A CONSULTATION WITH THE SURGEON. AS EACH INDIVIDUAL IS DIFFERENT AND LONGER TIME FOR SURGERY MAY BE REQUIRED.

      I (WE) CERTIFY THAT THIS FORM, ALONG WITH ALL OTHER FORMS HAVE BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ THEM OR HAVE HAD THEM READ TO ME AND UNDERSTAND THEIR CONTENTS.

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    • ACKNOWLEDGEMENT OF PRACTICE POLICIES AND PROCEDURES - BARIATRIC SURGERY  
    • 1. Once you have been seen by the Physician or Nurse Practioner a pre-determination will be started. This process takes between 4-6 weeks. Please contact your insurance company if it is within this timeframe. Pre Determination with the insurance companies that require additional information will not be sent until all information requested is received. The insurance company cannot make a pre-determination until they have all the needed information.

      2. We will collect your office specialist co pay + co insurance if applies at each visit. Your copayment/consultation fee can take up to three weeks to clear from your bank.

      3. If you are denied from your insurance company, you may appeal. Our office does not handle that appeal for you. You may utilize www.obesitylaw.com for appeals. We will furnish you with a copy of your charts/file to assist you.

      4. Unless told otherwise by the doctor, you are required, to follow a certain pre-surgery diet which consists of
      liquids for one week prior to surgery. If you do not adhere to the liquid diet your surgery will canceled by Dr. Jayaseelan.

      5. You will be required to pay your fees deductible, co-insurance one week prior to surgery. This amount varies from person to person, depending on the individual co-payment, co-insurance, deductible and health plan. A cancellation fee will be charged to you if you fail to cancel your surgery within 48 hours period.

      6. The adjustments needed for your follow up range from $0-$250 depending on your insurance coverage, surgeon, with the exception of self-pay patients. Self-pay patients receive 3 evaluations/adjustments, (fills/unfills), then they are $150 thereafter. New patients that were not banded by Dr. Jayaseelan and are uninsured will be charged $250 for evaluation and or any adjustment necessary you will not be seen unless you supply us with your surgery information and any fills done elsewhere to include OP REPORT AND ADJUSTMENT LOG.

      7. You and your health information are protected by HIPPA regulations. We will not give anyone information about you, unless we have written an authority to do so. The only exception is giving information to your insurance companies and disability companies. If you need more information on HIPPA laws please ask receptionist.

      8. Please be responsible about the insurance information you provide to our office. If your insurance company, policy, and or job changes, it is your responsibility to notify our office. If your benefits have changed and you did not notify our office in writing, you will incur all medical costs. This includes surgeon’s fees, anesthesia fees, facility fees, attorney’s fees and any costs included in recovering the amounts due to all that have provided care for you.

      9. If you self-pay $13,300* (private pay) for the Gastric Sleeve, regular follow up visits in our office are included for the first year following surgery: This is only if you paid the full amount of $5000 to Dr. Jayaseelan. This does not include testing we may refer you to afterwards for diagnostic purposes. Office visits will be $125 thereafter. We will attempt to bill insurance if possible.

      10. If you are self-pay $10,360* (private pay) for the Lap Band, you will receive one regular follow up visit in our office for your post-operative visit. 3 evaluations/adjustments, (fills/unfills). This is only if you paid the full amount of $4500 to Dr. Jayaseelan. This does not include testing we may refer you to afterwards for diagnostic purposes. Office visits will be $125 thereafter. We will attempt to bill insurance if possible.

      * This is only an estimate until you are seen in a consultation with the surgeon. As each individual is dif ferent and longer time for surgery may be required.

      I (we) certify that this form, along with all other forms have been fully explained to me, that I (we) have read
      them or have had them read to me and understand their contents.

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    • ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES  
    • I HEREBY ACKNOWLEDGE THAT I HAVE BEEN PRESENTED WITH A COPY OF NIRMAL S. JAYASEELAN, M.D. NOTICE OF PRIVACY PRACTICES.

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    • IN ORDER TO PROTECT YOUR PRIVACY, WE ASK THAT YOU COMPLETE THE FOLLOWING SECTION, WHICH WILL ENABLE US TO BETTER SERVE YOU IN THE FUTURE. PLEASE WRITE YOUR INITIALS BESIDE EACH STATEMENT. WE ALSO ASK THAT YOU ENTER THE NAME OF EACH PERSON YOU WOULD LIKE TO HAVE ACCESS TO YOUR ACCOUNT (THIS INCLUDES YOUR SPOUSE). ALSO, PLEASE SIGN AND DATE THE BOTTOM OF THIS FORM. YOU MAY UPDATE THIS INFORMATION AT ANY TIME. THANK YOU FOR YOUR COOPERATION.

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    • ACKNOWLEDGEMENT OF PRACTICE POLICIES AND PROCEDURES - GASTRIC BALLOON  
    • 1. UNLESS TOLD OTHERWISE BY THE DOCTOR, YOU ARE REQUIRED, TO FOLLOW A CERTAIN DIET WHICH CONSISTS OF LIQUIDS NIGHT PRIOR TO SURGERY. IF YOU DO NOT ADHERE TO THE LIQUID DIET YOUR PROCEDURE WILL BE CANCELED BY DR. JAYASEELAN.

      2. YOU AND YOUR HEALTH INFORMATION ARE PROTECTED BY HIPPA REGULATIONS. WE WILL NOT GIVE ANYONE INFORMATION ABOUT YOU, UNLESS WE HAVE WRITTEN AN AUTHORITY TO DO SO. IF YOU NEED MORE INFORMATION ON HIPPA LAWS PLEASE ASK RECEPTIONIST.

      3. A CANCELLATION FEE WILL BE CHARGED TO YOU IF YOU FAIL TO CANCEL YOUR PROCEDURE WITHIN 48 HOURS PERIOD.

      I (WE) CERTIFY THAT THIS FORM, ALONG WITH ALL OTHER FORMS HAVE BEEN FULLY EXPLAINED TO ME, THAT I (WE) HAVE READ THEM OR HAVE HAD THEM READ TO ME AND UNDERSTAND THEIR CONTENTS

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