Patient name *
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Thank you for choosing AboutSkin Dermatology for your health care needs. Our physicians are committed to your health, your treatment and your wellness. However, while we will provide therapeutic options, guidance and counseling, the achievement and maintenance of good health is ultimately your responsibility. Therefore, we expect all patients to follow the directions of their doctor(s) or provider(s). This means taking medications or supplements as prescribed, completing recommended testing as directed, (such as lab work, x-rays, MRI’s, and other imaging) and returning to our office for follow up at the recommended times (which may include discussion of any results received). If you have labs or test reports at our office, please make sure to call if you have not heard from us within 7-10 days for your results. Please do not assume that your results are negative if you have not heard from us; it is possible that we have not received your results, or that we were unable to get into contact with you.
The following is a further explanation of our office policies which we require you to read and sign prior to any treatment. All patients must also complete our patient information sheet before seeing our providers.
Photo Identification *
We require that each patient present a photo Id issued by a local, state, or federal government agency (e.g. a drivers license, passport, military Id, etc). The request is to protect the patient against identity theft for services.
We cannot bill your insurance company without a completed form and a copy of your insurance card. We will bill only insurance companies that we are contracted with or that we have prior approval from. Please remember that insurance is considered a method of reimbursing AboutSkin’s fees and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the overall charge. It is your responsibility to know the type of plan you have and to pay any deductible amount, co-insurance, co-pay or any other balance not paid for your insurance. Please be aware that some and perhaps all of the services provided may be non-covered services and may not be considered reasonable and necessary under Medicare and or other medical insurance. The balance may be your responsibility whether or not your insurance company pays for the services preformed by AboutSkin.
Insurance Plans We Do Not Participate With *
If your insurance company is one that we are NOT contracted with, full payment is expected at the time of service. However, we will be happy to give you a copy of your bill with the appropriate information regarding your visit for you to submit to your insurance company.
Missed Appointments *
For missed appointments not cancelled 24 business hours prior to your scheduled appointment time, our policy is to charge $40.00 for General Dermatology appointments, $150.00 for Mohs Surgery appointments and $80.00 for Cosmetic appointments. The full amount of collected deposits for specific appointments will also be forfeited if not canceled 24 business hours prior to your medical dermatology appointment and 48 business hours prior to your MOHS and/or cosmetic appointments. Please note that laser appointments require $250.00 deposit. This deposit will be forfeited if not cancelled 48 business hours prior. (These charges are solely your responsibility and not your insurance company’s). Additionally, if you arrive late for a scheduled appointment we reserve the right to reschedule and you would forfeit your deposit. Please help us serve you better by keeping scheduled appointments and arriving on time.
We accept the following forms of payment: cash, personal checks, Visa, MasterCard, Discover and American Express. All returned checks are immediately forwarded to our collection agency. You will be responsible for a $30.00 returned check fee, in addition to the full amount of the original check. In the event that your account is assigned to a collection agency, you will be responsible for any collection fees charged by the agency plus any other collection costs and reasonable attorney fees and court costs.
Generally, referrals need to come from your physician’s office. To obtain pre-authorization for procedures, please contact your primary doctor’s office at least two weeks prior to your appointment. It takes most insurance companies at least one week to receive the referral authorization. Please call us at least three business days prior to you appointment to check that your referral has been received.
Prescription Refills *
Please plan ahead for prescription refills. We ask that you contact your pharmacy three-five days prior to needing a refill. If you are out of refills, the pharmacy will contact our office for physician approval. Please Note: We will NOT refill narcotic prescriptions outside of normal business hours or on any weekends. We will not refill prescriptions if you are outside of your recommended follow-up window. As a general rule, no refills will be given for patients who have not been seen in the practice during the past 12 months for the specific prescription.
Calls to Medical Personnel *
Our primary goal at AboutSkin is to provide our patients with the best possible care. Our medical staff is devoted each day to our regular scheduled patients. Therefore, please understand when calling our providers or our medical assistants that they may not be able to immediately respond to your calls. All non-urgent calls will usually be returned by the end of the business day in which they are received.
Minor Patients *
All minors are required to have a parent or guardian present with them for each appointment. By law we are required to have a consent from a legal guardian to provide treatment to a minor. If a parent or guardian is unable to attend the appointment with the minor, then a signed Authorization to Treat a Minor is required prior to the appointment. If a minor comes to the office unattended and we do not have a signed and dated authorization from the parent or guardian for a specific day(s) of treatment, we will be unable to see the patient at that time, and the appointment will have to be rescheduled.
Annual Skin Cancer Screening Exams *
To ensure the best dermatological care, we strongly encourage our patients to have a full body check exam at least annually. If that exam cannot be performed at the initial visit due to the time needed to address your primary concerns, please make sure that you schedule an appointment as soon as possible.
* If I am diagnosed with a skin cancer or an atypical mole (dysplastic nevus), I need to return at least every 6 months for a full skin check because of the increased risk of developing future skin cancers. The goal of the more frequent visits is to catch skin cancers early while they are small and hopefully treated more easily. Skin cancer, if not caught early, can be life threatening. In addition, we urge you to be diligent and perform monthly self-exams. Let us know immediately if you become concerned about a lesion. Release of Medical Information to Family members *
Release of Medical Information, including pathology results and general medical information, to family members: I give my permission to release my medical information to the following family members:
Name Relationship Name Relationship Name Relationship I do not want any information released to my family members: Initial Terms *
I hereby authorize payment directly to AboutSkin Dermatology and authorize the release of and medical information necessary to process insurance claims. I understand that I am responsible to pay for all medical services not reimbursed by my insurance. I voluntarily consent to treatments for myself and/ or dependent(s). I have read and understand the Office Policies of AboutSkin and my questions have been answered satisfactorily. I understand that this is a contract and I agree to these policies.