I am interested in cosmetic advances and request that Dr. Mauriello’s office staff contact me with information regarding cosmetic services and products that he offers to his patients: ______YES ______NO
Please indicate preferred method of contact for such services is via (check, if applicable):
Email at the following address:__________
Cell or preferred telephone # __________
Home mailing address __________
May we leave a detailed message on your telephone _____yes _____no
Name_________________ Date______________JOSEPH A. MAURIELLO, JR., M.D.
NON-MEDICARE INSURANCE: I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE TO DR. JOSEPH A. MAURIELLO, JR, MD FOR ANY SERVICES AND/OR SUPPLIER FURNISHED TO ME BY DR. MAURIELLO AND NOT PAID DIRECTLY TO DR. MAURIELLO. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO MY INSURANCE COMPANY (IES) ANY INFORMATION NEEDED TO DETERMINE THOSE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.
Dr. Mauriello participates only with Medicare. Surgical fees are collected in advance unless other arrangements are made with Dr. Mauriello’s administrative staff. The office will provide medical information to the patient’s insurance company in order to facilitate reimbursement, but, in all cases, all surgical fees are the patient’s responsibility. It is the patient’s responsibility to secure knowledge about their “out-of network” benefits prior to scheduled office visits or surgery and ultimately to obtain any authorizations and predeterminations. Dr. Mauriello may elect to perform other procedure(s) due to the circumstances that arise during surgery. The patient will be informed of any such changes at that time. In such cases, the patient is responsible for full payment 90 days after surgery.
MEDICARE: I REQUEST THAT PAYMENT OF AUTHORIZED MEDICARE BENEFITS BE MADE ON MY BEHALF TO DR. JOSEPH A. MAURIELLO, JR, MD FOR ANY SERVICES FURNISHED SERVICES AND/OR SUPPLIES ME BY DR. MAURIELLO. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENT ANY INFORMATION NEEDED TO DETERMINE THOSE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES. I UNDERSTAND MY SIGNATURE REQUESTS THAT PAYMENT BE MADE AND AUTHORIZES RELEASE OF MEDICAL INFORMATION NECESSARY TO PAY THE CLAiM. Dr. Mauriello accepts the charge determination of the Medicare carrier as the full charge and I am responsible only for the deductible, coinsurance, and noncovered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier HMO’s, however, have out-of-network deductibles and coninsurance that are the patient’s responsibility. Cosmetic surgery and procedures are not covered by Medicare.
MEDICARE--MEDIGAP OR SUPPLEMENTAL (COMPLEMENTARY CROSSOVER INSURANCE): I FURTHER REQUEST THAT PAYMENT OF AUTHORIZED MEDIGAP BENEFITS BE MADE TO DR. JOSEPH A. MAURIELLO, JR, MD FOR ANY SERVICES AND/OR SUPPLIER FURNISHED TO ME BY DR. MAURIELLO. I AUTHORIZE ANY HOLDER OF MEDICARE INFORMATION ABOUT ME TO RELEASE TO MY MEDIGAP INSURER OR SUPPLEMENTAL INSURANCE CARRIER ANY INFORMATION NEEDED TO DETERMINE THOSE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.
I UNDERSTAND THAT A PROCEDURE THAT DR. MAURIELLO RECOMMENDS AND THEN PERFORMS MAY BE DENIED FOR REIMBURSEMENT AS NOT REASONABLE AND NECESSARY BY MEDICARE OR ANY OTHER INSURANCE. SUCH INSURANCES MAY CONSIDER THE TREATMENT OR PROCEDURE “OF QUESTIONABLE USEFULNESS” or NONCOVERED AND, THEREFORE, I MAY BE DIRECTLY LIABLE FOR SUCH PAYMENT TO DR. MAURIELLO OR TO MY INSURANCE COMPANY. I FURTHER UNDERSTAND THAT MEDICARE AND OTHER INSURANCES WILL DENY COSMETIC SURGERY AND I WILL ALWAYS BE LIABLE FOR SUCH SURGERY AS TOLD IN ADVANCE BY DR.MAURIELLO AND HIS STAFF.
I AUTHORIZE THAT PHOTOGRAPHS TAKEN OF THE FACE, EYELIDS, OR OTHER BODY PARTS AFFLICTED BY DISEASE BY DR. MAURIELLO OR HIS STAFF MAY BE USED FOR INSURANCE OR RESEARCH PURPOSES, ELECTRONIC WORLD WIDE WED PRESENTATIONS, PUBLICATION, PRESENTATION AT SCIENTIFIC COURSES AND MEETINGS AS WELL AS PERSONAL ADVERTISING FOR DR. MAURIELLO AND HIS PRACTICE.
ALCOHOL________YES________NO FREQUENCY--ONCE A DAY_____
FAMILY HISTORY
DIABETES_______YES________NO
HIGH BLOOD PRESSURE _______YES________NO
CANCER_______YES________NO
OTHER________YES________NO
Mother died at age _____ from ____________
Father died at age _____ from ____________
Name_____________________________________
Procedure Date: __________________________
PRE-OPERATIVE INSTRUCTIONS:
1. Please obtain a letter of medical clearance within four (4) weeks of scheduled surgery date (Form Attached) as requested by Dr. Mauriello.
2. DO NOT eat or drink past midnight the night before EXCEPT FOR CARDIAC AND ANTI-HYPERTENSIVE MEDICATIONS that are taken with a SIP OF WATER the morning of surgery. IF you are diabetic, check with your MD but generally no hypoglycemic agents are taken the morning of surgery
3. Please DO NOT TAKE: ASPIRIN, ECOTRIN, BUFFERIN, ANACIN, VITAMIN E
OR ANY MULTIVITAMINS FOR A MINIMUM OF TEN DAYS PRIOR TO SCHEDULED PROCEDURE DATE.
4. Please AVOID: GINGKO, GARLIC, GINSENG, FISH OILS, and FLAXSEED (HERBS MAY
HAVE PHARMACOLOGIC EFFECTS) FOR TWO (2) WEEKS
PRIOR TO SCHEDULED PROCEDURE DATE.
5. Please AVOID: ADVIL, MOTRIN, IBUPROFEN OR ANY OTHER ANTI-
INFLAMMATORY MEDICATIONS FOR ONE (1) WEEK PRIOR
TO SCHEDULED PROCEDURE DATE.
6. If you are taking such medications but especially COUMADIN, HEPARIN or PLAVIX, please consult with your Cardiologist or Primary Care Physician for instructions regarding resumption of medications post procedure.
Dr. Mauriello must be notified in writing in regards to:
COUMADIN, PLAVIX, OR ASPIRIN THERAPY PRIOR TO THE PROCEDURE.
7. TAKE *TYLENOL FOR PAIN.
8. If you have *Asthma, bring your inhaler with you to the medical center. If necessary, take 2 puffs of your inhaler before you come.
9. *Diabetics: Do NOT take diabetic medication of insulin in the morning of your procedure if you are scheduled to receive anesthesia or sedation in order to avoid hypglycemia. Confirm this recommendation with your prescribing physician.
INSTRUCTIONS ON DAY OF PROCEDURE
1. Please leave money, jewelry and valuables at home.
2. Shower/Bathe/Shampoo on the day of the procedure. You may use deodorant and may brush
your teeth. (No make-up, powder, lotion, perfume, wigs or bobby pins.)
3. Wear glasses if you need them, please leave contact lenses at home.
4. Wear loose comfortable clothing.
5. Bring all insurance cards and ID cards.
6. Bring x-rays or MRI reports of films if requested by your doctor.
Please make arrangements for a responsible adult to drive you home and remain with you for 24 hours after surgery.
All surgery is performed at a JCAH fully licensed outpatient surgical facility.
Kindly contact the office should you have any questions.
MEDICAL CLEARANCE FOR SURGERY
Date: ___________________________
TO MEDICAL CONSULTANT
Dear Dr.__________________________
Your patient _________________________ is scheduled for a ___________________________________
on ____________________ at ___________________________________ under monitored sedation performed by a board-certified anesthesiologist.
Kindly perform a consultation for Pre-Operative Medical Clearance and include the following tests at your discretion: CBC, SMA-7(BMP), PT, PTT, URINALYSIS (CHEST X-RAY, PREGNANCY TEST) as necessitates. All patients over 65 and those with a cardiac history generally require an EKG within one month of procedure date.
HISTORY:
Current Medical Problems:
Previous Surgery:
Allergies:
PHYSICAL EXAMINATION:
B/P:___________________ Pulse:__________________
Skin:
ENT:
Heart / Lungs:
Abdomen:
Neurological:
Extremities:
Other:
Assessment/ Impression:
Plan:
PATIENT IS / IS NOT CLEARED FOR THE PROCEDURE ON _____________________.
Please fax results of labs, EKG and any additional tests performed to 908-608-1299.
Please comment of ability to stop Aspirin and Plavix for 10 days and Coumadin for 5 days prior to surgery, if applicable. Thank You.
Peri-Operative Instructions and Patient Registration
Post-Operative Instructions
** Call the office immediately if you experience increased *pain, *mucous discharge, or *swelling that is greater than the previous day (or pain or bleeding under eye patch). Call the office immediately if you have a fever over 101 degrees.
1.Check vision daily by covering each eye and reading the newspaper print while blinking frequently to clear the tear film and to keep the eye moist (some tearing and mucous discharge are to be expected). Call immediately if there is a change in vision in either eye.
2.If eye is not patched, apply bags of frozen peas or ice (in Ziploc Bag) over the sterile gauze that has been placed over the eyelids.
a.Apply ice 10-15 minutes on and 15 minutes off every hour while awake for the first 48 hours after surgery.
b.Continue the application of the bags of frozen peas or ice four times a day for 10 to 15 minutes for the next two days.
c.Do not apply compresses of any kind on the fifth day after surgery.
d.Apply hot compresses the sixth day after surgery- four times a day for 10-15 minutes. Boil water. Dip washcloth in moderately warmed water (allowed to cool—DO NOT SCALD
SKIN) and place over sterile 4x4 gauze (interface between eyelid wounds and washcloth).
e.Use eye drops (one drop) in the involved eye four times a day UNTIL IT RUNS OUT and
wear eye shield at bedtime ( if not patched) – DO NOT RUB EYE.
f.If eye does not open, place sterile soaked in cooled boil water gauze over eye
g. Please do not remove any Steri-strips or tape applied by Dr. Mauriello
3.If eye is patched, local treatments including ice, eye drops, or shields are no longer necessary, but call Dr. Mauriello immediately if there is pain or bleeding under the eye patch.
4.It is better to bathe for the first week. If you must shower, do not allow water to directly hit the wounds or get in your eyes. Pat wounds dry.
5.All bending and lifting must be avoided for one week. In addition, do not engage in any strenuous activity or physical exercise for 18 days after surgery. Gradually resume activity.
6.Resume all medications the day of surgery, but do not take Aspirin/ Vitamin E/ Motrin for one less post surgery unless otherwise directed by your physician in consultation with Dr. Mauriello.
7.Take Tylenol or Extra Strength Tylenol- two tablets every four hours as needed.
8.Someone should assist you the first 48 hours.
a.Sleep on two or more pillows or in a reclining chair for first 48 hours.
If you sleep on your side, please wear eye shield for one month after surgery.
b.Avoid alcohol for 48 hours and smoking one week post surgery.
c.Eat lightly the night of surgery, try clear liquids first.
d.You may usually resume a normal diet the day after surgery.
e.Wear sunglasses to protect the incisions from the sun and for comfort.
9.Please bring eye drops to first post-op visit with the eye shield provided by the surgical facility.
10.Driving is prohibited until the first post-op visit. At that time, if your vision has returned to its preoperative level with no complications, permission to drive will be given.
11.If any oral antibiotic is prescribed, use as directed but take after meals and obtain over-the-counter acidophilus to prevent yeast problems by replenishing bacterial flora.
Call Dr. Mauriello if any diarrhea, abdominal pain, or vaginal yeast infection.
12.Dr. Mauriello may prescribe oral Prednisone:
i.3-20mg tabs on the 1st and 2nd days after surgery
ii.2-20mg tabs on the 3rd day after surgery.
Take the Prednisone after breakfast, all at once, followed by antacid. If there is a
history of GI ulcer disease, please inform Dr. Mauriello. In any invent, please consult
your physician.
13. Call for an appointment 5 to 7 days after surgery
