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  • English (US)
  • Patient Information

    Please complete this form before your visit. This form is for all patients (new and existing, virtual and in-person visits).
  • **Please note: You will be sent a link via email and text from our electronic medical records system (called athena) as well as from Dr. Khalil at the approximate schdeuled time of your visit for the video call. 

  • **Please note: You still will be sent a link via email from our electronic medical records system (called athena) for a video call. Pleease kindly ignore this correspondence, as Dr. Khalil will telephone you directly at the approximate time of your visit.

  • Emergency Contact Information

    (Optional)
  •  -

  • Medical Information

  • Photos are recommended for virtual visits. If you are not able to send photos using the below, please email the images to info@dkdermatology.com.

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  • We recommend full body skin exams to check for skin cancer at least once per year for all adults. Please schedule with the front desk if you are interested.

  • Questions? Call (646.793.4226) or email us (info@dkdermatology.com).

  • Insurance information

  • Accepted Insurances: Aetna, Blue Cross Blue Shield (except with member ID prefix JLJ), Centivo, Cigna, Bright Health, EmblemHealth HIP (except Enhanced Care or Essential policies, not GHI), First Health (not Healthfirst), Humana, Medicare, Nippon Life Insurance, Oscar, and UnitedHealthcare (Liberty and Freedom only). We do not accept Worker's Compensation policies.

    Please Note: If you have two insurances, please make sure to list both in the correct order (or the insurance company will deny the claim).

     

  • Clear photos of both sides of the insurance card are required. If you are not able to submit photos using the above, please email them to info@dkdermatology.com.

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  • Insurance Terms

    Copay - The fixed amount you pay for a health care service (e.g. $50 copay per visit). 

    Deductible - The amount you pay for health care before your insurance benefits take effect. If you have a $500 deductible, you pay $500 before your insurance will begin to pay. If you have an unmet deductible you will receive a bill after your visit, even if we are considered a "covered, in-network physican". This is because with a deductible, the patient first has to pay for their medical expenses. An office visit is usually several hundred dollars, and the exact price is determined by the insurance company. 

    Coinsurance - The percentage of health care costs you pay once your insurer covers its share (e.g. if you have 20% coinsurance, you pay $2.00 of every $10.00 in health care costs).

    Please contact your insurance company if you have any questions about your individual policy's applicable coverage and costs before your visit.

  • We highly recommend you call your insurance company before your visit to determine your healthcare benefits and costs.

  • Pharmacy Information

  • Consent

  • 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 amounts. I understand that the provider does not accept Worker's Compensation-related insurance packages or policies.

    I agree that DK Dermatology PLLC may use my health information for diagnosis, treatment, payment, insurance billing, and health care operations. I consent to access and share my medical information with my insurance company, health care providers, pharmacies, and hospitals. 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 virtual visits are processed by insurance companies like in-person visits, and I may be responsible for copay, deductible, and co-insurance. I understand that many but not all skin conditions can be diagnosed and treated through a virtual visit. A virtual visit is not as accurate as an in-person visit. The virtual visit is not refundable. 

    Definitions

    Copay - The fixed amount you pay for a health care service (e.g. $50 copay per visit). 

    Deductible - The amount you pay for health care before your insurance benefits take effect. If you have a $500 deductible, you pay $500 before your insurance will begin to pay. 

    Coinsurance - The percentage of health care costs you pay once your insurer covers its share (e.g. if you have 20% coinsurance, you pay $2.00 of every $10.00 in health care costs).

    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.

    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 (e.g. hepatitis and human immunodeficiency virus).

    We recommend yearly (at least) skin exams for all adults to check for skin cancer by a dermatologist. We also recommend monthly self-skin checks for all adults. 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 for health payments (e.g. copay, deductible, co-insurance) by 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 deductible charges, coinsurance charges, copay charges, or any other such charge) it is my responsibility to pay this balance off in a timely manner. If my bill is not paid in full within 90 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.

  • Coronavirus (COVID-19) Consent

  • The office takes several precautions to prevent the transmission of coronavirus, including cleaning the office multiple times per day, wearing gloves and masks, and screening guests and staff for symptoms of coronavirus. However, it is not possible to guarantee a zero percent risk of exposure. By coming to the office, I understand that there may be a risk of exposure to coronavirus, and I do not hold the office responsible for this. 

    Signs, Symptoms, and Risk Factors of Coronavirus
    - fever
    - chills
    - cough
    - fatigue
    - body or muscle aches
    - headache
    - sore throat
    - congestion or runny nose
    - nausea, vomiting, or diarrhea
    - loss of taste or smell (one of the earliest symptoms)
    - shortness of breath, difficulty breathing, or requiring more energy than usual to breathe
    - being in close proximity to a person with the above symptoms

    By coming to the office, I agree that I have not had any sign, symptom, or risk factor (see above) for coronavirus for at least 14 days before my visit.

    Please wear a mask on the day of your visit (required by our building in order to enter). Please keep your mask on inside the office for the entire duration of your visit.

    Please do not bring guests or family members with you. We can instead include them by phone or video if applicable.

    When you do come to the office, we will check your temperature, check your sense of smell, and provide you with gloves. If you have any sign of coronavirus, we will re-schedule your appointment.

    By signing below, I certify that I understand and agree to this consent form. 

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