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Santaanaskincare.com

PHOTODYNAMIC TREATMENT (BLU LIGHT WITH LEVULAN)
A procedure is now available that treats active acne as well as older acne leaving your skin smoother. The procedures are called Photodynamic Acne Treatments using Levulan. The Photodynamic Acne Treatment is a process by which a photosensitizing agent (Levulan) is applied to your skin. The Levulan is then activated with a specific wavelength of light, which “turns it on”. Levulan has been used extensively for the treatment of a variety of different skin conditions, and the FDA for the treatment of sun-damaged skin approves it. Levulan is 20% solution of Aminolevulinic Acid (ALA), ALA is a natural substance found throughout your body, as it is a precursor for hemoglobin synthesis. You would be unable to make red blood cells to carry oxygen without ALA in your body. Consequently, it is a “natural” product found in all humans. Acne results from the obstruction and inflammation of the sebaceous glands, and it affects the 80% of the human population. Acne typically begins in adolescence with hormonal changes. However, there are many older individuals who suffer from “adult acne”. There are several different presentations of acne, ranging from comedonal (blackheads and whiteheads), papular, pustular, and cystic acne. In many cases, many presentations of the acne can be present on an individual simultaneously. Prior to Photodynamic Acne Treatments, the best available treatment option for cystic acne was Accutane. However, with Accutane, there are many systemic side effects including birth defects, liver abnormalities, mood depression, and virtually all patients get dryness and blurred vision at night. Photodynamic Therapy provides a viable alternative for all types of acne treatment. Photodynamic Acne Treatments are done as follows: the Levulan is applied to your skin and left on for 30-60 minutes. Levulan is a clear solution and painless. Levulan is then activated with a specific wavelength of light called the BLU-U or acne laser. This takes about eight minutes. The Levulan targets active cells called Acne sebaceous glands. These cells preferentially absorb Levulan, and these cells are targeted by the Levulan once it is activated; hence the term Photodynamic Therapy. The Levulan will also target small, benign bumps on the skin and the papules of acne rosacea. Skin oiliness is decreased. Incentives of Photodynamic Therapy
• Well tolerated (essentially painless. • Easily performed in a clinical environment. • Non-invasive (no needles or surgery required). • Excellent cosmetic outcome (particularly sensitive areas of the face). TREATMENT STEPS:
1. Patients who have a history of recurring cold sores (herpes simplex type I) should start oral Valtrex 500mg tablets twice daily for three days, starting this prescription the morning of your PDT treatment. The prescription for this product will be ordered for you. 2. Make sure your skin is clean and free of all make-up, moisturizers, and sunscreens. Bring a hat, sunglasses, and a scarf (when appropriate) to the clinic. 3. Photography will be done by the staff before the Levulan is applied 5. An acetone scrub is performed. This will enhance the absorption of Levulan and provide 6. Levulan is applied topically to the whole area to be treated (such as whole face, back of the hands, extensor part of the forearms). This is done by the provider performing the procedure. 7. The Levulan is left on for forty-five to seventy minutes before any light treatment. 8. The Levulan is activated with the BLU-U or laser light. This unique spectrum of light activates the Levulan beginning with low energy levels. This is painless, but requires about eight to nine minutes to complete. 9. Post-treatment instructions will be given to you to care for your improved skin. CLIENT CONSENT FOR LEVULAN PHOTODYNAMIC TREATMENT
Levulan (Aminolevulinic acid 20%) is a naturally occurring photosensitizing compound, which has been approved by the FDA to treat pre-cancerous skin lesions, called actinic keratoses. Levulan is applied to the skin and subsequently “activated” by specific wavelengths of light. This process of activating Levulan with light is termed Photodynamic Therapy. The purpose of activating the light Levulan is to improve the appearance and reduce acne rosacea, acne vulgaris, sebaceous hyperplasia, decrease oiliness of the skin, improve texture and smoothness by minimizing the pore size. Any pre-cancerous lesions are also simultaneously treated. The improvement of these skin conditions (other than actinic keratoses) is considered an “off-label” use of Levulan. I understand that Levulan will be applied to my skin for forty-five to seventy minutes. Subsequently, the area will be treated with a specific wavelength of light to activate the Levulan. Following my treatment, I must wash off any Levulan on my skin. I understand that I should avoid direct sunlight for twenty-four hours following the treatment, due to sensitivity. Anticipated side effects of Levulan treatment include discomfort, burning, swelling, redness and possible skin peeling – especially in any areas of sun damaged skin and pre-cancers of the skin. Other side effects included lightening and darkening of skin tone and spots, and possible hair removal. The peeling may last many days, and the redness for several weeks if I have an exuberant response to treatment. I consent to taking photographs of my face before each treatment session. I understand that I may require several treatment sessions spaced two-four weeks apart to achieve optimal results. I understand that I am responsible for payment of this procedure if it is not covered by health insurance. I understand that medicine is not an exact science; and there can be no guarantees of my results. I am aware that while some individuals have fabulous results, it is possible that these treatments will not work for me. I understand that alternative treatments include topical medications, oral medications, cryosurgery, excisional surgery, and doing nothing. I have read the above information and understand it. The doctor and her staff have answered my questions satisfactorily. I accept the risks and complications of the procedure. By signing this consent form, I agree to have one or more Levulan treatments. Signature ________________________________________ FINANCIAL POLICY
Please read our financial policy and indicate your agreement by your signature. We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. All patients must complete the appropriate forms before seeing a skin care provider. FULL PAYMENT IS DUE AT THE TIME OF SERVICE.
We accept cash, check, Visa, American Express, Discover, Mastercard & Care Credit.
Private pay patients: Non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan or paid by cash, check, or credit card at the time of services. Insured patients: If you have insurance, we will help you obtain benefits for covered services. If you have insurance with a company for which we are not providers, we will give you properly completed “super bills” so that you can file your own insurance claims and be reimbursed to the extent of your coverage. We only file claims to insurance companies that we are participating providers for. Filing a claim is not a guarantee of payment. Many of our services are considered to be a cosmetic luxury and are therefore not covered by insurance. You are responsible for the full payment of any denied claims. We provide Botox for cosmetic purposes only, which is NOT covered by insurance. Insurance: This is a contact between you and your insurance company. In many cases, we are not a party to this contract. We will inform you if we are a party to your contract, and we will handle your claims according to our agreement with your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance usual and customary charges, etc., other than to supply actual information as necessary. In the event that you receive a statement with a balance due after insurance adjustments, you are responsible for timely payment on your account. Balance due terms: Your signature below indicates your agreement with our terms for any unpaid balance due. Any unpaid balances to customer accounts are subject to being sent to a collection agency after repeated statements are sent to the address provided by the patient. If it becomes necessary to employ an attorney or collection agency to collect an unpaid balance due, those fees will be added to the balance due. Notice: All products and services offered through Santa Ana Skin Care Clinic are non-refundable. Responsible Party Signature: ____________________________________ Date: _____________ PRIVACY POLICY
This notice describes how information about you may be used and disclosed and how you can get access to this information. Please review it carefully. This notice summarizes how we handle your information, and provides further details of our privacy policies and procedures. How we may use and disclose your information: We use health information about you for your
treatment, to get paid for treatments, for administrative purposes, and to evaluate the quality of care
that you receive. For example, your health information may be shared with other providers to whom
you are referred. Information may be shared by paper mail, electronic mail, fax, or other methods. We
may use or disclose your health information without your authorization for these reasons. Beyond
those situations, we will ask for your written authorization before using or disclosing your health
information. If you sign an authorization to disclose information, you can later revoke it in writing to
stop further uses or disclosures.
Your rights: In most cases you have the right to look at or get a copy of your health information that we
use to make decisions about you. If you request copies, we wil charge you a cost-based fee and these
copies will be made within 30 days. You also have the right to request a list of certain types of
disclosures of your health information that we have made. If you believe your health information is
incorrect or information is missing, you have the right to request that we correct the existing
information or add the missing information.
Our legal duty: We are required by law to protect the privacy of your health information; provide this
notice about our privacy policies; follow the privacy practices that are described in this notice; and seek
your acknowledgement of receipt of this notice. We may change our privacy policies at any time.
Privacy complaints: If you are concerned that we have violated your privacy rights, our privacy policies,
or if you disagree with a decision we made about access to your health information, you may contact
the person listed below. You may also send a written complaint to the U.S. Department of Health and
Human Services.
If you have any questions or complaints, please contact:
Office Manager Santa Ana Skin Care Clinic, PC 2205 Miguel Chavez Suite E Santa Fe, NM 87505 Responsible party signature:__________________________________________ Date:_______________ PROCEDURE CLAIM REVIEW FORM
Santa Ana Skin Care Clinic would like to make you aware that in the event we should submit a claim to your insurance company for a procedure reviewed here at our clinic, your insurance provider always reserves the right to review and deny any claim they receive. We may be able to find out for you if the procedure does not require a pre-authorization, but these procedures are stil subject to review and possible denial. The only time your insurance company is obligated to pay any amount is if they give you a confirmed pre-authorization number which we will keep in your chart. However, if the treatment amount is applied towards a deductible, then you wil stil be held responsible for payment. Your signature below indicates you agree to abide by the policy in this form. I, _____________________, have read and understand the Insurance Procedure Claim Review Form. HOME CARE INSTRUCTIONS
FOR PATIENTS FOLLOWING PHOTODYNAMIC SKIN REJUVENATION
Remain indoors, if possible, and avoid direct sunlight. Take analgesics such as Tylenol or Advil if necessary. Apply Hydrocortisone 1% ointment, Vaseline or Medical Barrier Cream. Your skin will feel dry, keep it moisturized. You may take a shower. Men should not shave their face if it was treated. You may take analgesics. Any discomfort usually subsides by Day Three. You should avoid sunlight and try to remain indoors on Day Two. The photosensitivity to sunlight is usually gone twenty-four hours after treatment, but may last as long as forty hours. You should soak treated areas with a solution of one (1) tsp. White Vinegar in one (1) cup of cold water for twenty minutes every four-six hours. Ice may be applied directly over the vinegar soaks. The area should be patted dry and Hydrocortisone 1% ointment reapplied following vinegar soaks. You may begin applying make-up once any crusting has healed. The area may be slightly red for a few weeks. If make-up is important to you, please see one of us for a complimentary consultation on Glo•Minerals Make-up, which is pharmaceutical grade and anti-inflammatory. It also acts as a broad spectrum sunscreen and is effective for masking redness. The skin will feel dry and tightened. A good moisturizer should be used daily. Try to avoid direct sunlight for one week. No beaches! Use a sunscreen with a minimum of SPF 30 for four months. Sun block with Titanium (available in our clinic) is especially effective to protect your newly regenerated skin. If you have any problems, please call our office at 505-954-4422.

Source: http://www.santaanaskincare.com/Portals/2066/web-content/Forms/PDTBLULIGHTCONSENT.pdf

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