Informed Patient Consent
I give my permission for the Physicians and staff of Natural Image Skin Center to treat me as deemed necessary in the expertise of their professional judgement.
I understand that medical care requires my cooperation, and I will follow my doctor’s orders and prescriptions. If indicated, I will make and keep appointments for follow-up care and call the office to note any changes or concerns in my condition.
I authorize my doctor to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such medical care to third party payers, including Medicare.
I authorize and request that my insurance company, in lieu of reimbursing me directly, pay to the doctor or medical group any benefits for services rendered.
I understand that my medical insurance carrier may pay less than the actual bill for services. I agree that I may be responsible for payment of all services rendered on my behalf or my dependents.
I understand I may be billed by an outside laboratory for work that is performed in this office, if my insurance company does not have a contracted lab or facility, or if services are not covered by my insurance company.
In the event that I chose to provide Natural Image Skin Center(“NISC”) with my e-mail address, I hereby authorize NISC to contact me using the e-mail address(s) I provided, and agree to allow NISC to continue to contact me using e-mail until I advise NISC, in writing, that they no longer may contact me using e-mail. In return for allowing NISC to contact me using e-mail, NISC promises not to release, sell or otherwise distribute any e-mail address(s) I provide to any other person or entity without my express written authorization.
I authorize the physician(s), mid-level providers or staff of Natural Image Skin Center to educate me regarding skin care products or devices suitable for my disease state or diagnosis. I understand that I can opt-out from receiving this information at any time by writing to Privacy Officer, 108 Bilby Road Suite 202 Hackettstown, NJ 07840.