I have completed this form accurately and completely. I am responsible for any 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: copays, deductibles, coinsurances, 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 to have a referral on the correct insurance form prior to my visit or I will be responsible for the entire visit cost. I understand that it is my responsibility to know if the physician and lab is a contracted in-network physician/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 understand that if the provider is not in-network with my Secondary Insurance/Medicare Supplement and I do not have out-of-network benefits, I may receive a bill for which I am liable to pay. I understand that the provider does not accept any HealthShare plans, including but not limited to MultiPlan, PHCS, OneShare, Trinity HealthShare, and more.
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.
By signing this form, I confirm that I understand the following definitions:
Copay - The fixed amount you pay for a health care service at the time of your visit.
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.
Specialist Visit - All dermatology visits are considered "Specialist Visits" by insurance companies. Specialist fees apply, including but not limited to specialty copays, coinsurances, and deductibles. Please note that dermatology visits are not considered "preventative" by insurance companies, including for annual skin exams/skin cancer screenings.
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/consultation office visit.
I understand that it is my (the patient's) 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 (at least) yearly 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.