** If secondary or tertiary insurance does not apply to you, then you may leave those blank.
If patient is a minor please enter responsible party information. (Note: We do not bill absent parents, the adult presenting the minor for care is the responsible party.)
If we have a contract with your plan, we will file a claim with your insurance company. The amount for which you are responsible (any deductibles, copays, percentages or non-covered services) is required at the time of service. If arbitrary determination of a participating insurance company determines that services are cosmetic or not medically necessary, the patient/guarantor will be responsible for the outstanding balance. If you do not have one of the plans with which the practice is contracted, the total cost of your visit is required at the time of service. If at any time you are concerned about the cost of a procedure proposed by the doctor, you may ask for someone from the business office who will be happy to discuss the cost with you.
For your convenience in paying, this office accepts MasterCard, Discover, Visa, and American Express in addition to cash and checks. There will be a $50 fee for any returned checks. We also accept Care Credit for all Cosmetic Services.
Southeastern Skin Cancer & Dermatology8331 Madison Boulevard, Suite 300Madison, Alabama 35758(256) 705-3000
I understand that, under the Health Insurance & Portability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that the information can and will be used to:
Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.Obtain payment from third party payers.Conduct normal healthcare operations such as quality assessments and physician certifications.
I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. HIPPA forms are available for download on our website forms page or in our office. I understand that the organization (Southeastern Skin Cancer & Dermatology) has the right to change the Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.
SOUTHEASTERN SKIN CANCER & DERMATOLOGYCONSENT FORM FOR MINOR SURGERY • CRYOSURGERY • BIOPSYDuring your visit, the dermatologist may need to perform cryosurgery or a skin biopsy to treat or evaluate your skin condition. Please review and sign the consent form below. You will be given ample time to discuss the procedure if the doctor determines cryosurgery or a biopsy is necessary. This will serve as a standing consent for this and any and all future treatments (only of these types), however verbal consent will ALWAYS be obtained PRIOR to any treatment.
CONSENT FOR: CRYOSURGERY OR BIOPSY PROCEDURE
PURPOSE:(1) A biopsy is a surgical procedure used to obtain a sample of tissue for microscopic examination to aid the physician in diagnosis. The entire lesion may not be removed in this procedure. Further medical or surgical treatment may be needed when the diagnosis is made.
(2) Cryosurgery is the use of liquid nitrogen to freeze the skin lesions that respond well to sub-zero temperatures. The process is commonly used to freeze precancerous lesions known as actinic keratosis or solar keratosis. The treatment is also used to freeze the virus infections that cause many common warts as well as other lesions.
PROPOSED TREATMENT:(1) I understand that a biopsy requires obtaining a sample of tissue and is a surgical procedure. As in any surgical procedure, there are certain risks that include but are not limited to bleeding, post-operative pain, infection, reactions to sutures, anesthetics or topical antibiotics, and scarring. Although all reasonable efforts will be made to minimize the possibility of these potential complications, no guarantees can be made since many factors beyond the control of the physician (such as the degree of sun damage or patient compliance with post-operative instructions) affect the ultimate healing.
A pathologist will examine the tissue obtained in this biopsy procedure to assist in providing a specific diagnosis for you. I understand I may receive a separate bill from the pathologist or laboratory for this microscopic examination.
(2) Complications of applying liquid nitrogen to the skin may include but is not limited to skin irritation, redness, temporary discomfort, blistering, infection, or permanent loss of pigmentation. After the lesion has been treated, most patients develop a crust or scab that lasts for 1-2 weeks.
OTHER ACKNOWLEDGEMENT DISCLOSURE:I am able to read and understand English. I understand that I will have the opportunity to discuss my procedure with the physician or other professional who is to perform the procedure and have all of my questions answered to my satisfaction.
PHOTOGRAPHIC CONSENT:I authorize and consent to the taking of a series of photographs of the surgical areas for the use of Southeastern Skin Cancer & Dermatology for my chart, in lecturing, or in print (medical journal or text)/video (medical education purposes) publication. NO IDENTIFYING PATIENT INFORMATION WILL BE INCLUDED.
Optional, Non-required Convenience
If you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient. We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you. This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment. Co-pays due at the time of the visit will, of course, still be due at the time of the visit.If you have any questions about this payment method, do not hesitate to ask. Any charges over $100 will be additionally verified and approved by you via phone or other method before processing.