Acknowledgement Of Office Policies

General Patient Authorization: I hereby authorize providers of DSA Dermatology to render care to me during my office visits and to fulfill the orders of my physicians, including consultants, associates, and assistants of the physicians’ choice.

Receipt of Notice of Privacy Practices: DSA Dermatology's Notice of Privacy Practices provides information about how DSA Dermatology may use and disclose protected health information about me. The Notice of Privacy Practices contains a Patient Rights section describing my rights under the law. I acknowledge that I have had the opportunity to review the Notice of Privacy Practices of DSA Dermatology. DSA Dermatology reserves the right to change the Notice of Privacy Practices.

Cancellation Policy: If a patient cannot adhere to a scheduled appointment, it is the patient’s responsibility to call the office to cancel within 24 hours of the scheduled appointment. DSA Dermatology reserves the right to charge a $50 fee if a patient does not cancel his/her appointment within 24 hours or a loss of a deposit if a patient does not cancel a surgical appointment within 24 hours. Administrative fees incurred for failure to provide cancellation notice are not billable to insurance or any other third party payor. These policies include appointments with all providers and estheticians.

If at any time you should need a copy of your medical records, we require a written release to be signed and dated. The form is available at our front desk and can be requested by email. Please allow up to 15 business days to complete your request. If your request is urgent, please mark the request as urgent and someone from our staff will contact you to expedite your request. Absent providing a secure fax number, records must be MAILED to your address of record. Copies of blood work and pathology reports are provided at no charge, copies of your complete medical record or office notes will require $25 fee.

DSA Dermatology requires a written records release form to transmit records to any physician or medical organization that is not listed as your referring physician. If you have a consulting physician you would like to have listed as an authorized recipient of your medical information, please request and complete a release form for each physician you wish to receive your records.

Contact Permission: In the event that DSA Dermatology needs to contact you (the patient), regarding an appointment, lab result, medication, or any other reason, it is permissible to

Expiration of and Right to Revoke Authorization to Disclose Protected Health Information: I understand that I can withdraw my permission set forth above at any time by giving written notice stating my intent to revoke this authorization to the person or organization named under “Release of Medical Information” and “Contact Permission”. I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.

Physician Assistant, Nurse Practitioner, & Esthetician Information DSA Dermatology may staff physician assistants, nurse practitioners, and estheticians to assist in the delivery of medical dermatology care. A physician assistant (“PA”) is not a doctor but is a graduate of a certified training program and is licensed by the Texas Physician Assistant Board. Under the supervision of a physician, a PA can diagnose, treat, and monitor common acute and chronic diseases. Supervision does not require the constant physical presence of a supervising physician, but rather overseeing their work. In collaboration with a physician, nurse practitioners can diagnose, treat, and monitor common acute and chronic diseases. Estheticians provide services as directed by a PA, nurse practitioner, or physician. I understand that at any time I can request to see a physician. I have read the above and hereby consent to the services of a PA, nurse practitioner, or esthetician for my health care needs.

Unaccompanied Minors (Under 18 Years Old): New patients who are minors must have a parent or legal guardian present for the new patient visit. Many times parents/guardians find themselves unable to accompany their teen or young adult children to appointments. Should you wish for us to see your teen/young adult child when they arrive at the office unaccompanied, please read, indicate, and sign below:

Proof of Identity: DSA Dermatology requires proof of identity on file. I understand that I will be asked to provide a photo ID such as a driver’s license at check-in. This will be scanned into your private medical record as a means to document who we are treating.

By signing this Acknowledgement of Office Policies you acknowledge that you have read, understand, and accept the above policies