I have completed this form accurately and completely. I am responsible for information that is omitted and hold the provider harmless for medical decisions made without this information.
I understand that it is my responsibility, and not the responsibility of the office, to know the benefits and limitations of my insurance. I understand that I am responsible for charges not paid by my insurance company. These include but are not limited to co-pays, deductibles, co-insurances, procedures, lab tests, and referrals. I understand that it is my responsibility to know whether or not my insurance covers non-emergency care in New York state. If a referral is required, it is my responsibility to know this and have a referral on the correct insurance form prior to my visit or I will be responsible for the visit cost. I understand that it is my responsibility to know if the physician and lab is a contracted in-network facility recognized by my insurance plan, or I may be responsible for out-of-network charges. I understand that the provider does not accept and is not in-network with any Worker's Compensation-related insurance packages/polices or any Medicaid, including as a secondary insurance and or Medicare supplement.
I agree that DK Dermatology PLLC may use my health information for diagnosis, treatment, payment, insurance billing, credit card payments and chargebacks, and other such healthcare operations. I consent to access and share my medical information with my insurance company, relevant medical providers (such as my Primary Care Physician/PCP), pharmacies, and hospitals via telephone, fax, email, and or voicemail. I acknowledge receipt of the Notice of Privacy Practices. The Notice of Privacy Practices may change at any time, and I can obtain a copy at the front desk or via email. I agree that by including my phone number and or email address, I am consenting to be contacted via phone, text, voicemail, and email with my medical information.
I understand that telehealth/virtual visits are processed by insurance companies like in-person visits, and I may be responsible for any applicable copays, coinsurances, and deductibles. I understand that many but not all skin conditions can be diagnosed and treated through a telehealth/virtual visit, however, a telehealth/virtual visit is not as accurate as an in-person visit. Telehealth/virtual visits are not refundable.
Definitions
Copay - The fixed amount you pay for a health care service.
Deductible - The amount you must pay out-of-pocket for healthcare before your insurance pays. If you have an unmet deductible, you will receive a bill after your visit even if we are considered a "covered, in-network physician". An office visit is usually several hundred dollars, and the exact price is determined by the insurance company and not by the provider or their office.
Coinsurance - The percentage of health care costs you pay once your insurer covers its share.
***Note: Please contact your insurance company if you have any questions about your individual policy and healthcare benefits or costs before your visit.***
I understand that if a biopsy/excision site requires sutures (stitches), I must return in 7 days for suture removal, wound check, and a discussion of the pathology results. I acknowledge that this follow-up visit is subject to copays, coinsurances, and deductibles and that these charges are not included in the initial encounter office visit.
I understand that it is the patient's (my) responsibility to schedule follow-up visits, especially if my condition is not improving, not responding to treatment, worsening, bleeding, hurting, enlarging, and or changing. I will not hold the office liable if my condition worsens due to my lack of follow-up.
To protect against the transmission of blood-borne diseases if an accidental blood or bodily fluid exposure occurs, I understand and agree that it may be necessary to test my blood for certain diseases (such as Hepatitis and Human Immunodeficiency Virus/HIV).
It is recommend for all adults to have yearly (at least) skin exams to check for skin cancer by a dermatologist and monthly self-skin checks. I understand it is my responsibility to schedule skin exams if I am interested. I also understand that most insurance companies do not consider annual skin exams by a dermatologist to be "preventative" and may not offer "preventative" coverage for said exams.
If I am paying by credit card, I agree that my credit card will be kept on-file and used for healthcare payments (such as copays, coinsurances, and deductibles) by the Elavon secure credit card processing system. I agree that if I cancel my appointment without providing 24 hours of advance notice that I will be responsible for a $50 fee.
I understand that if I have an outstanding balance with the practice (whether due to Self-Pay charges, insurance copay charges, insurance coinsurance charges, insurance deductible charges, or any other such charge) it is my responsibility to pay off this balance in a timely manner. If my bill is not paid in full by me and or my insurance company within 90 calendar days of my visit, I understand that my account may be adjudicated by a collections agency, for which I am therefore responsible for any collections fees, legal fees, or other such fees.
By signing below, I certify that I understand and agree to this consent form.