PLEASE REMEMBER – to bring your Insurance Card(s), Medicare Card, Driver’s License, co-pay, and credit card, and a complete list of your medications
(Failure to do so may result in the rescheduling of your appointment)
We confirm all appointments with automated calls.
I hereby give express consent to receive dialed, autodialed, pre-recorded or SMS Text calls from or on behalf of Orchard Park Dermatology at the telephone number(s) provided above. I understand that consent is not a condition of purchase or services received.
Office Policies and Financial Agreements
It is your responsibility to pay all co-pays, deductibles, co-insurance, and any non-covered or denied services.
If your insurance company pays the claim directly to you, please forward check accompanied by insurance paperwork to our office.
I authorize the release of medical information to my primary care or referring physician and as necessary to process insurance claims or prescriptions.
I understand that I am responsible for presenting a copy of correct and current insurance information prior to, or at the time of service. If the insurance information presented is incorrect, I am responsible for all charges incurred at the time of service.
I authorize payment of medical benefits to be made to Dr. Peter Accetta for all services furnished to me.
I have read the above Financial Policy and understand that I am financially responsible for all charges whether or not paid by my insurance. I understand and agree if the debt is not paid within (30) days we will begin to incur an interest rate of 1.5% monthly or 18% annually until the debt is paid. I understand and agree if my account becomes overdue, it will be turned over to a collection agency, which may be based on a percentage at a maximum of 25% of the debt and all costs and expenses, including reasonable attorney fees and court costs we incur in such collection efforts. The agency or law office may report to one or more credit reporting agencies.
My signature constitutes my acknowledgment that I have been offered an opportunity to review the Notice of Privacy Practices from Orchard Park Dermatology containing a more complete description of the uses and disclosures of my health information. This signature states an understanding of the above information and authorization for our medical personnel to examine and treat this patient as well as authorizes the release of medical information to the insurance company. I UNDERSTAND THAT THIS IS A LIFETIME SIGNATURE AUTHORIZATION.
CURRENT OR PAST PROBLEMS WITH: (Review of Systems)
Check Yes or No, explain as necessary
FAMILY HISTORY: Check following conditions that have occurred in your family.
Consent for treatment
I hereby consent to all surgical procedures and treatment, including, but not limited to, any laboratory and biologic test and administration of anesthetics, which are deemed appropriate and necessary for the treatment of the disorder about which I have consulted this office (I understand that this consent does NOT limit my right to refuse any treatment or procedure if I so choose). I am aware that a scar may result from any surgical procedures. I may have, and that the type of scar cannot be determined before surgery. I further agree that the information listed on this form that I have provided is correct to the best of my knowledge.
I hereby give express consent to receive dialed, auto-dialed, pre-recorded or SMS Text calls from or on behalf of Orchard Park Dermatology at the telephone number(s) provided above. I understand that consent is not a condition of purchase or services received.
It is your responsibility to pay all co-pays, deductibles, co-insurance, and any non-covered or denied services. If your insurance company pays the claim directly to you, please forward the check accompanied by insurance paperwork to our office.
All product sales are final