pdf form

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Name
Address
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Sex
Marital Status
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How did you find our office? (circle)

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Financial Policy

Financial Policy
Assignment of Benefits and Responsibility of Charges

Thank you for selecting The Dermatology Center for your dermatological needs. The following information is provided to prevent any misunderstanding regarding payment and financial responsibility.

Medicare

Our physicians are participating Medicare providers and accept Medicare assignment. Our office agrees to accept the charge determination of the Medicare carrier as the full charge. You will be responsible for the deductible, 20% co-insurance, and any non-covered services. If you have a secondary insurance, we will submit to the carrier any remaining balance.

HMO/PPO/Other Insurance Coverage

If you have Insurance through a company we have contracted with, we will require a copy of your insurance card and your driver’s license. ALL CO-PAYMENTS ARE DUE PRIOR TO SEEING THE PHYSICIAN/PA/NP. If your insurance carrier requires a referral from your primary care physician, this must be present at the time of service. It is your responsibility to keep track of the referral expiration dates and the number of visits given by your primary care physician. You will be responsible for any services denied by your insurance carrier as not medically necessary and/or not covered. You are also responsible for any copayment, deductible, co-insurance and non-covered services. It is your responsibility to notify us if you have changed insurance carriers, since your last visit, and to provide us with your new insurance card and information. In addition, if you do not have a valid referral at the time of service or do not have active insurance, you will be responsible for all charges incurred.

Laboratory

Depending on your insurance carrier’s policy, you may be required to pay separate co-pays and/or deductibles for any specimen taken during your visit.

Self-Pay Patients

If you have no insurance and are a self -pay patient, you are responsible for the balance due at the time of your visit.

Cosmetic Procedures

A deposit may be required for certain cosmetic procedures. Payment in full is required before the procedure is performed. Deposits are non-refundable unless your appointment is cancelled at least 24 hours in advance.

Refunds

There are no refunds given on any medical or cosmetic procedures.

Cancellation Policy

If you cannot make your appointment, you are required to cancel your appointment at least 24 hours in advance. If you miss your appointment (without cancelling at least 24 hours in advance), there will be a $25 charge billed to you for each missed general dermatology appointment, and $100 for each missed surgical appointment.

Returned Checks and Collection

A charge of $20 will be made for all returned checks. Your bill will be automatically sent to a third-party collection agency if your patient balance is not paid within 3-6 months of the original due date.

I understand the financial policy of the office and will follow all rules set above. I hereby request payment of all authorized benefits be made on my behalf to New York Dermatology PC for the services rendered.

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HISTORY AND INTAKE FORM
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Past Medical History: (please circle all that apply)
Skin Disease History: (please circle all that apply)
Do you wear Sunscreen?
Have you ever regularly used a tanning salon?
Do you have a family history of Melanoma?
Do you have a family history of Basal Cell Carcinoma or Squamous Cell Carcinoma?
Do you have asthma, hay fever, allergies, eczema, or dry skin?
Have you ever fainted in a Doctor’s office?
Have you ever had any laser, cosmetic, or plastic surgery procedures performed on you?
Have you received your influenza vaccination during the current season?
If 65 years of age or older, have you ever received a pneumonia vaccination?
Social History: (please circle all that apply)
Alcohol Consumption
I acknowledge my agreement to the terms set forth in the information above. I understand that this consent shall remain in force from this time forward.
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF THE NOTICE OF PRIVACY PRACTICES

I hereby give my consent for The Dermatology Center/ New York Dermatology P.C. to use and disclose protected health information about me to carry out treatment, payment and healthcare operations. The Dermatology Center’s “Notice of Privacy Practices” provides a more complete description of such uses and disclosures. This notice describes how medical information about me may be used and disclosed and how I can get access to this information. I have the right to review the “Notice of Privacy Practices” prior to signing this consent. The Dermatology Center reserves the right to revise its “Notice of Privacy Practices” at any time.

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