Circumcision Form

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Child`s Name:

Gender:

Male
Female

Date of Birth:

Address:

Home Phone #:

City:

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Apartment #:

Email Address:

Referred By:

Pharmacy Name, Address and Phone Number:

Name of Father or Legal Guardian:

Name of Mother or Legal Guardian:

Date of Birth:

Driver’s License #:

Occupation:

Employer:

Work #:

Cell Phone:

Insurance Co. Name:

Policy/ID #:

Group #:

Mailing Address:

City & State:

Name & Ages of other children:

PAYMENT IS DUE WHEN SERVICES ARE RENDERED

Person Responsible for Payment:

Address and Contact #:

Financial Policy

The following information is provided to avoid any misunderstanding or disagreement concerning payment for professional services. We will file Insurance as a COURTESY: however. YOU ARE ULTIMATELY RESPONSIBLE FOR YOUR CBILD’S CBARGES.

1. Our office participates with a variety of insurance plans. It 1s your responsibllitv to:

Brims your insurance card and photo LD. at every visit
Pay your Co-Payment and/or any deductibles at each visit. Payment can be made by cash, check or credit card.
We accept VISA, MasterCard, American Express and Discover.
Pay in full for any medical care or services that are not covered by your insurance plan.

2. If your child has insurance that we do not participate with, or your child does not have insurance, payment in full is expected at the time of service. Your child will be a ‘Ttivate Pay’ patient in our office. We offer a prompt payment discount to ’T'rivate Pay” patients, if the charges are paid at the time of service.
3. If your insurance plan is a HMO or POS policy it may require you to choose a PCP (Primary Care Provider). You will need to choose a physician from our practice. If your innirance card lists another physician’s name, we will sec ymir child, but you be ’Private Pay’ unni a « ver has been changed to one of our physicians.
4. Proof of insurance is not a guarantee of coverage or ofpayxnent.
5. Secondary Insurance: We do not file secondary insurance. You may request a copy of the claim to file yourself.
6. You are financially responsible for any amount not covered by your ehild•s health insurance plan.
7. You are financially responsible for all charger Incurred in your child’s care and treatment.
8. If you have questions about your insurance, we can help where possible. However, specific coverage issues should be directed to your insurance company members services department. The telephone number is usually located on your insurance ca«L In the event that payment is erroneously denied by the insurance cartier, it is your responsibility to pursue action with the insurance carrier, as the policy is a legal contact between the patient and the insurance carrier.
9. If you fail to make payment in full for services that are rendered to you, your outstanding balance will De sent to an outside collection agency. Accounts am considered past dun after 90 days. You will be responsible for any feea associated with the collection of your outstanding balance. Failure to meet your financial obligations with this office could lead to dismissal from the practice.
10. To protect your child’s records, we ask you to provide our office with a driver’s license or other picture ID. Annually, or as changes occur, we will ask you to sign our financial policy and update your registration information. We will scan your insurance card and ID into your child’s electronic medical chart We will check these documents prior to releasigg your child’s records.
11. la cases of divorce and/or separaaon, the legal guardian and/or the pmson bringing the child in for services will be held responsible for paying any balance originating from that visit. If you provide legal documentation that someone other than the legal guardian is Enancially responsible and you provide billing information for that responsible party, we will attempt to bill that party. However, if the balance is unpaid by that person, you will be held responsible for the balance on your child’s account.

Late Arrival/No Show Policy Appointments are scheduled specifically for each patient. If you arrive mom than l5 minutes late for your appointment, you will be asked to reschedule to another day or may be worked back in to the schedule/moved to the end of the day. If you cannot keep your appointment, we ask you to cancel at least 24 hours prior to the appointment time. If ypu “no show” three times we reserve the right to discharge your child from the practice. Appointments that art missed or not cancelled 24 hours prior to the scheduled appointment time will be charged a No Show fee of $25.00.

ADVANCED BENEFICARY NOTICE
These services may NOT be covered by your insurance carrier. The purpose of this list is to help you make an informed choice about whether or not you choose for yoor child to receive certain services. The fact that yoor insurance carrier does not cover a service does not mean that you should not receive that service, itjust means that you have a choice to whether your child If you choose to receive one of these services in ae office and it is later denied by your insurance carrier, receive it or not you will be financially responsible for the balance on your account.

FOR YOUR INFORMATION

Considerations for Non-Ritual Circumcision
After the birth of a male infant, parents are asked whether they would like their son circumcised. Circumcision is the surgical removal of all or pan of the foreskin covering the end of the penis. A decision to circumcise or not to circumcise a newborn son is a personal choice. Most newborn circumcisions are done for traditional, cultural or religious reasons but even this choice should not be made without careful thought. We encourage you to read the following information and discuss your decision with knowledgeable advisers; your obstetrician or midwife; and your child’s pediatrician.

Reasons to Choose to have a Circumcision
1. Custom - In the United States, circumcision of the male infant is most commonly done by custom. Many parents feel it is important that their son “looks like his father,” or peers.
2. Cleanliness - Circumcision does make cleanliness of the penis easier. A normal secretion, which is cream colored and somewhat waxy, is formed under the intact foreskin. If allowed to accumulate, it can irritate the head of the penis and may lead to an infection. Circumcision prevents this but the build-up can also be prevented by proper hygiene during bathing. Circumcision does not eliminate the need for proper hygiene; though it does makes it easier.
3. Decreased incidence of infection - Circumcision will slightly reduce the risk of urinary tract infections in males, both as infants and also in adulthood. The incidence of such infections in the first year of life is reduced from 1 in 100 (hundred) to 1 in 1000 (thousand). Circumcision has also been shown to be associated with a lower risk for some sexually transmitted infections, including HIV, particularly in areas where the use of safe sexual practices is low
4. Prevention of paraphimosis - Rarely, parents may rebact a still-tight foreskin while vigorously cleansing the penis to eliminate the waxy secretion mentioned above. If the foreskin is left retracted, it can act as a toumiquet, decreasing blood supply to the tip of the penis. This may need to be surgically corrected. Circumcision prevents this uncommon complication from occurring.
5. Prevention of cancer of the penis - This is an extremely rare condition of adult-like. It is less common in circumcised men and is usually found only in conditions of very poor hygiene, suggesting that proper hygiene provides as much protection as circumcision.

Reasons to Choose NOT to have a Circumcision
1. Pain - Research and common sense lead to the conclusion that, in the absence of some form of analgesia (local pain medicine), the infant experiences pain during the procedure. There are medications available that diminish or eliminate pain, which are both safe and effective. The American Academy of Pediatrics recommends that these be used. Clinicians in the Department of Obstetrics and Gynecology and the Division of Newborn Medicine at the Brigham and Women’s Hospital routinely uses pain relief medication if circumcision is chosen and we urge you to discuss this with your obstetrician.
2. Surgical risk - The vast majority of circumcisions are performed without any complications whatsoever. However, no surgical proceaure (and circumcision is a surgical procedure) can be totally risk-free. Complications include: bleeding, infection, adhesion formation, cosmetic deformity, trauma to the penis, excessive removal of the foreskin, and functional defects. These occur once every 500 circumcisions.
3. Change in sensation - Some believe that circumcision leads to a decrease in sexual pleasure later in life. There is insufficient data to substantiate this belief.
4. Expense - There is a cost attached to the procedure. Some health insurance plans do not provide coverage for circumcision. If you have concerns aboot your coverage, we urge you to contact your insurer before the procedure is performed, as patients will be responsible for both hospital and physician charges.

Timing of circumcisions
Although parents have the option of delaying circumcision until a time beyond the newborn period, these “delayed” circumcisions represent a more involved surgical procedure, usually performed with general or regional anesthesia. It is important to note that I in 100 uncircumcised adults may require a circumcision for medical reasons.
Finally, in 1999, the Academy of Pediatrics Task Force on Circumcision concluded that, “...existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision [and] ...parents should determine what is in the best interest of their child.” The American College of Obstetricians and Gynecologists supports this statement. We support the conclusion that parents are the best judges of the appropriateness or lack of appropriateness of circumcision for their children.

CONSENT FOR CIRCUMCISION

I understand that cécumcision is a procedure in which the foreskin (fold of skin that covers the end of the penis) is surgically removed. Many parents are interested in having circumcision done for ethnic, cultural, religious or social reasons; but there is still some medical controversy about the need for the procedure on a routine basis. The nature of a circumcision, and the benefits to be reasonably expected compared with alternative approaches have been explained to me.

I understand that there is a chance that risks or complications related to the circumcision may occur. These complications include, but are not limited to the following:
Minor problems are short-term:
a. Slight oozing or slight bleeding may be noted at the surgical site
b. Infection of the circumcision site or at the tip of the penis can occur
c. Irritation of the exposed tip of the penis (glans) as a result of contact with stool or urine is not uncommon and usually responds to cleansing with water
Long-term minor problems can include:
a. The urethra, which leads from the bladder to the tip of the penis, can be damaged at its point of exit.
b. Scarring of the penis can occur
c. Unintended removal of the outer skin layer (or layers) of the penis can occur.
d. An opening that is too small for the foreskin to retract over the penis can occur if too little foreskin is removed.
Malor problems are very uncommon but can include:
a. Complete removal of the skin covering the shaft of the penis has rarely been reported.
b. Significant bleeding may occur, requiring stitches to stop the bleeding.
c. Serious, life-threatening bacterial infection can occur.
d. Partial or full removal (amputation) of the tip of the penis has also been rarely reported

MD/NP will perform the procedure. The procedure may also involve the participation or resident physicians, fellows and/or physician assistants. My physician will determine whcn it is necessary for others to participate in the circumcision of my child.

I understand that blood or other specimens removed for necessary diagnostic or therapeutic reasons may later be disposed of by the hospital. These materials also may be used by BWH or other academic or commercial entities, for research, educational purposes (including photographing), or other activity, if in furtherance of the Hospital’s missions.
Additional comments (if any):

The above risks and benefits have been explained to me. I have had an opportunity to fullAy inquire about the risks and benefits of circumcision and its alternatives. All my questions were answered to my satisfaction and I consent to the circumcision of my child.

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Signature (Parent / Degal Guardian)

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Signature (Practitioner)

CIRCUMCISION FORM

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