PREMIER DERMATOLOGY CONSENT FORM
- Consent to Treatment: I voluntarily consent to receive medical and health care services that may include examinations, diagnostic procedures and treatments. If patient is under the age of 18, I give permission for the patient to receive follow-up care from the physicians and staff at Premier Dermatology PLLC in my absence.
- Assignment of Benefits: I authorize my insurance company to make direct payment to the provider of services for the profession of medical expense benefits allowable under my current insurance policy. That is, my insurance company will make direct payment to Premier Dermatology for services rendered rather than to myself.
- Financial Responsibility: I agree to pay all charges for medical or other services not covered by my insurance company. I further understand that I am responsible for all collection, small claims court and/or attorney fees necessary to collect this debt, as per the Financial Policy.
- Outside Laboratory Charges: In the event that I have a skin biopsy, I consent to have my biopsy sent to the pathologist my doctor determines most appropriate for arriving at an accurate diagnosis of my condition. I understand that this may incur a second bill from the pathologist who interprets my pathology. This may also be the case for certain other routine lab tests that my doctor may order to make an accurate medical diagnosis.
- HIPAA Consent: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal law that governs the use and disclosure of a person’s health information. The following statements cover the basics of your rights as a patient under HIPAA.
- Protected health information may be disclosed for treatment, payment, or health care operations.
- Premier Dermatology has a Notice of Privacy Practices and the patient has an opportunity to review this notice. To obtain a copy of the notice ask the office staff. Premier Dermatology reserves the right to change the Notice of Privacy Practices.
- The patient has the right to restrict the uses of his or her protected health information, but Premier Dermatology does not have to agree with those restrictions.
- The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
- Premier Dermatology may offer or refuse treatment based upon the execution of this consent.
PREMIER DERMATOLOGY CANCELLATION POLICY
A primary goal at Premier is to provide skillful and timely service for all patients. To do so, we require individual appointments to be cancelled at a minimum of 24 hours in advance or it will be considered a No-Show appointment. Thank you in advance for your cooperation.
PREMIER DERMATOLOGY FINANCIAL POLICY (Effective February 2021)
- All patients are required to complete the Premier Dermatology Patient Registration form and Medical History, sign the Consents page as well as provide insurance card (if applicable), and a photo ID before clinic services are rendered.
- Patients are responsible for payment:
- For cosmetic & self-pay medical patients, FULL PAYMENT is due at the time of service.
- For aesthetician and massage services, appointments must be secured with an active credit card or existing Open House credit at the time of booking.
- For medical patients with insurance, a co-payment and/or co-insurance is due at the time of service, including unmet deductible.
- For payments made with a credit card, any overpayments will be refunded to that card.
- All charges not paid by insurance are due by the patient.
- Money on account for cosmetic services may also be used for payment of medical bills.
- A non-refundable deposit will be collected when making an appointment if the patient has shown a history of missed appointments.
- Medical office visit - $150
- Mohs Surgery visit - $1,000
- Medical or Cosmetic surgery visit - $500
- Cosmetic visit (injectables, lasers, devices, facials, massages) – estimated full value of service
- If the patient comes to the appointment, the deposit will be applied to the service and any overage will be refunded.
- Payment plans for medical appointments are available on request for large balances and must be signed by patient and secured with a credit card to be charged monthly.
- Patient balances that extend beyond 180 days may be assessed a finance charge of 1% per month.
- Collection efforts on past due balances will include fees assessed to the patient. Fees may be as high as 50% of the outstanding balance if sent to a collection agency who will also report to the credit bureaus. If sent to Small Claims court, fees could be up to $200 plus garnishment.