METROPOLIS DERMATOLOGY

Welcome to Metropolis Dermatology. We are thrilled to have you as a new patient. To get you registered, we require some basic demographic information.

PREFERRED PHARMACY (required)
We send medications electronically to pharmacies

INSURANCE
Please upload a front and back copy of your insurance card(s)

Make sure you understand your insurance policy.
You may or may not have a COPAY, but your costs will be dependent on your DEDUCTIBLE and COINSURANCE. Covered services may still incur out-of-pocket costs to you after insurance is billed. It is up to you to understand your individual plan.

Signatures are required on all components prior to being seen.

We take most major PPO plans and Medicare. However, a few select PPO plans are not in-network. While we do check your eligibility for you at the time of the visit, it is your responsibility to confirm with your insurance company (or companies if you have a secondary policy) that we are currently under contract with your specific plan. Each plan has its own stipulations regarding the coverage of, and payment for, medical services; therefore, it is your responsibility to know your plan's benefit policies

including co-payments, deductibles, and coinsurance prior to your appointment.

Co-pays & Outstanding Balances: Please be prepared to pay any past balances on your account.

Payment of co-pays and non-covered service payments will be required prior to the time of service. For your convenience, we accept cash and card.

Non-Covered Services: If you are receiving a non-covered service (cosmetic), please be prepared to pay

for the service in full at the time of service. Cosmetic procedures including, but are not limited to: Botox, Dermal Fillers, Laser Treatments, Microneedling, and Vitamin Injections. We do not bill insurance for

Providing Proper Documentation: In order to protect our patient's privacy and for insurance purposes,

you will be required to provide a photo ID for us to keep in your medical records.

I understand that all insurance deductibles, co-payments, and denials for primary or secondary insurance policies will be my financial responsibility.

OFFICE & FINANCIAL POLICIES
We take most major PPO plans and Medicare. However, a few select PPO plans are not in-network. While we do check your eligibility for you at the time of the visit, it is your responsibility to confirm with your insurance company (or companies if you have a secondary policy) that we are currently under contract with your specific plan. Each plan has its own stipulations regarding the coverage of, and payment for, medical services; therefore, it is your responsibility to know your plan's benefit policies including co-payments, deductibles, and coinsurance prior to your appointment.

Co-pays & Outstanding Balances: Please be prepared to pay any past balances on your account. Payment of co-pays and non-covered service payments will be required prior to the time of service. For your convenience, we accept cash and card.

Non-Covered Services: If you are receiving a non-covered service (cosmetic), please be prepared to pay for the service in full at the time of service. Cosmetic procedures including, but are not limited to: Botox, Dermal Fillers, Laser Treatments, Microneedling, and Vitamin Injections. We do not bill insurance for these treatments.

Providing Proper Documentation: In order to protect our patient's privacy and for insurance purposes, you will be required to provide a photo ID for us to keep in your medical records.

I understand that all insurance deductibles, co-payments, and denials for primary or secondary insurance policies will be my financial responsibility.

IDENTIFICATION AND TREATMENT PHOTO CONSENT

I authorize Metropolis Dermatology to take photographs of procedures and treatments for documentation purposes if necessary, which will be kept in my medical records. I understand that I may revoke this authorization at any time by notifying Metropolis Dermatology in writing. The revocation will not affect any actions taken before the receipt of this written notification.

PHOTOGRAPHS WILL NOT BE USED FOR MEDIA OR MARKETING PURPOSES. THIS IS SOLELY FOR

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate

It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompletely rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must Be Arbitrated

It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean both the mother and the mother's expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician or patient to collect or contest any medical fee shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any malpractice claim, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law

A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred of approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of the arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of California law applicable to healthcare providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions

All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statue of limitations, or (2) the claimant fails to purse the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect ot any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation

This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect

Patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement.

NOTICE OF PRIVACY PRACTICES

We are required by the Health Insurance Portability & Accountability Act of 1996 (HIPAA) to provide confidentiality for all medical/mental health records and other individually identifiable health information in our possession. This Notice is to inform you of the uses and disclosures of confidential information that may be made by Metropolis Dermatology, and of your individual rights and Metropolis Dermatology's legal duties with respect to confidential information.

Ways in which we may use and disclose your protected Health information:

We may use and disclose at my discretion your medical records for each of the following purposes only: treatment, payment, and health care operations.

Treatment means providing, coordinating or managing mental health care and related services. Payment means activities such as obtaining payment for the mental health care services I provide for you from your insurance or another third party payer. Health care operations include the business aspects of running a practice.

We may contact you to provide appointment reminders or other services that may be of interest to you. We will disclose your protected health information to any person you identify that is involved in payment for your care.

We will use and disclose your protected health information when required by federal, state or local law. There are certain situations in which we are required by ethical standards to reveal information obtained during therapy to persons or agencies - even if you do not give permission. These situations are as follows: (a) If you threaten grave bodily harm or death to yourself or another person, we are required by ethical standards to inform the intended victim and/or appropriate law enforcement agencies; (b) if you report to us your knowledge of physical or sexual abuse of a minor child or of an elder (over 65) or any sexual conduct/contact with a minor, we are required by law to inform the appropriate child welfare or social agency which may then investigate the matter; (c) if we are required by a court of law (court order) to turn over records to the court or if we are ordered to testify regarding

Any other uses and disclosures will be made only with your written authorization. You will be provided with an authorization form upon request. A separate form will be needed for each request for release of information. The authorization for release of records is valid until it expires or is revoked. You may revoke authorization in writing. We are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

Please sign to indicate you understand our use of your information for treatment, payment, and health care operations as stated above.

COVID-19 ACKNOWLEDGEMENT

This form is your acknowledgment that you are aware of the risks of contact with a healthcare provider during the time of the COVID-19 pandemic. Derm Within Reach takes all necessary precautions to protect you and our staff. However, we are unable to guarantee that infection by COVID-19 will not occur if you see a provider in person.

I hereby agree to indemnify, hold harmless and release the Practice, its owners, members, officers, employees, contractors, agents, and representative, from any and all claims, causes of action, liabilities, damages, and demands whatsoever, in law or equity, which I (and my heirs, executors, administrators and assigns) shall or may have, for, upon, or by reason of my contracting COVID-19, including any claim resulting from my transmission of COVID-19 to any other person or thing, and any claim from my heirs, executors, administrators or assigns related hereto.

By signing below, I acknowledge I have read this waiver in full and I hereby agree to the terms that I assume the risk of potential COVID-19 exposure inherent in the nature of a medical in-person visit.