Patient Forms


Demographics
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Financial Policy
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Ins Assignment Agreement
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Text Consent Form
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Privacy Notice
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Authorization for Release of Confidential Info
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Minors Consent Form
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Summary of Notice of Privacy Practices


This summary is provided to assist you in understanding Privacy Practices

Our Notice of Privacy Practices contains a detailed description of how our office will protect your health information, your rights as a patient and our common practices in dealing with patient health information.  Please refer to that Notice for further information.

Uses and Disclosures of Health Information.  We will use and disclose your health information in order to treat you or to assist other health care providers in treating you.  We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by us or other health care providers.  Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students.

Uses and Disclosures Based on Your Authorization.  Except as stated in more detail in the Notice of Privacy Practices, we will not use or disclose your health information without your written authorization.

Uses and Disclosures Not Requiring Your Authorization.  In the following circumstances, we may disclose your health information without your written authorization:

  • To family members or close friends who are involved in your health care;
  • For certain limited research purposes;
  • For purposes of public health and safety;
  • To Government agencies for purposes of their audits, investigations and other oversight activities;
  • To government authorities to prevent child abuse or domestic violence;
  • To the FDA to report product defects or incidents;
  • To law enforcement authorities to protect public safety or to assist in apprehending criminal offenders;
  • When required by court orders, search warrants, subpoenas and as otherwise required by the law.

Patient Rights.  As our patient, you have the following rights:

  • To have access to and/or a copy of your health information;
  • To receive an accounting of certain disclosures we have made of your health information;
  • To request restrictions as to how your health information is used or disclosed;
  • To request that we communicate with you in confidence;
  • To request that we amend your health information;
  • To receive notice of our privacy practices.

If you have a question, concern or complaint regarding our privacy practices, please refer to Our Notice of Privacy Practices for the person or persons whom you may contact.

FINANCIAL POLICY

Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy.

All patients must complete our registration form in full before seeing the doctor.

Payment is due at the time of service.  We accept cash, checks, and credit cards.  If needed, a payment plan can be established with prior credit approval.

If you have insurance, which will pay our doctor directly, and which we can verify, we still require that you pay all co-payments, deductibles, co-insurance and charges for non-covered services at the time of service.

If you are a member of an HMO or PPO that requires a referral form from your primary care physician, you are responsible to bring this form with you for your visit.

Missed appointments- If you are unable to keep an appointment kindly give us 24 hours notice.  We reserve the rights to charge a fee for any appointments that are not cancelled within 24 hours. Please, help us serve you better by keeping scheduled appointments.

Important Information About Biopsies

Dermatologists traditionally take a sample (surgical biopsy) of suspicious skin growths or rashes in order that microscopic examination of the sample can be performed, and a diagnosis made.

This is to inform you that the work associated with processing each biopsy, preparing slides, microscopically examining the slide, and issuing a report of the resulting diagnosis (together known as surgical pathology) is a distinct and separate service from the biopsy itself, and there will be a separate charge.