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If there is a family history of Melanoma, which relation to the patient? blanks
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With my consent, Dermatology Consultants of Sacramento may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Dermatology Consultants’ Notice of Privacy Practices for a more complete description of such uses and disclosures.I have the right to review the Notice of Privacy Practices prior to signing this consent. Dermatology Consultants reserves the right to revise the Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to: Privacy Officer, Dermatology Consultants of Sacramento, 5340 Elvas Ave, #600, Sacramento, CA 95819.With my consent, Dermatology Consultants may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results, among others.With my consent, Dermatology Consultants may mail to my home or other designated location any items that assist carrying out TPO, such as appointment reminders and patient statements. I have the right to request that Dermatology Consultants restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.By signing this form, I am consenting to Dermatology Consultants of Sacramento’s use and disclosure of my PHI to carry out TPO.I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Dermatology Consultant of Sacramento may decline to provide treatment to me.
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Dermatology Consultants of Sacramento’s policy is to maintain the confidentiality of your medical records, also referred to as Protected Health Information (PHI). Our office will not disclose personal or medical information about you unless authorized by you or mandated by law.
As a patient, you have the right to determine who may receive medical information about you from our office. Some patients elect no one other than themselves to receive information, while others elect specific family members or friends who may receive their information. In order to assure your PHI continues to be secure, please take a moment to answer the question below.
Please list the first and last name of any individual allowed to receive your Protected Health Information. Please limit to three (3) people. If no one other than you is allowed, please list “self only”.
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If, at any time, you wish to make a change, please ask us for another form. Thank you for your cooperation.
Thank you for trusting Dermatology Consultants of Sacramento to partner in your health care. This financial agreement should answer questions regarding patient and insurance responsibility for services rendered. Please read this agreement, ask us any questions you may have, and sign in the space provided. If requested, you will be given a copy of this agreement for your records.
I have received this financial policy and understand that regardless of any insurance coverage I may have, I am responsible for payment of my account. I understand that delinquent accounts will be referred to a collection service. If it becomes necessary to send my account to a collection service, I agree to pay for all costs and expenses, including reasonable attorney fees. I also acknowledge that I may request and receive a copy of this financial agreement for my records.
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Your insurance coverage is a contract between you and the insurance company, and it is your responsibility to know your insurance benefits. As a courtesy, we will bill both your primary and secondary insurance companies. We will submit your claims and assist you in any way we reasonably can to help get your claims processed. In order to do this, we must receive all the information necessary to bill. If the information is not supplied, you will be billed, and payment in full will be your responsibility and will be expected within 30 days of receipt of statement.
We participate in the Medicare program. You are responsible for your co-insurance, any deductibles that have not yet been met, and services that are identified as patient responsibility on your Medicare Explanation of Benefits. We strive to inform our Medicare patients of services that will not be covered. We may ask you to sign an Advanced Beneficiary Notice, which lists our fees and notifies you of your financial responsibility for certain medical services. Managed Care: Many patients are enrolled in Managed Care Products. In order for us to obtain referrals and/or pre-authorizations for procedures, it is important that we have your current insurance information. Depending on individual policies, your procedure may not be a covered benefit. It is your responsibility to check for optimal coverage and policy limitations, and to obtain referrals as required by your insurance company. Please contact your insurance company with questions regarding your coverage.
Patient Responsibility for Payment
You are responsible for payment of any co-payment, co-insurance, deductible or service not covered by your insurance, handling, collection or attorney fees. If you do not have insurance, you are responsible for payment of all services. Co-payments are due at the time of your service. Patient due balances noted on your monthly statement are due within 30 days of receipt. Charges for minor children will be billed to the parent with whom the child resides. We will bill appropriate insurance if all required information is provided. We will not bill or contact a non-custodial parent on behalf of the custodial parent. If insurance payment results in a credit balance, it will be refunded to you within 30 days.
We understand that financial circumstances vary from patient to patient. If you are unable to pay your patient due balance in full, you must call our business office at (916) 739-1505 to make payment arrangements. Non-Payment: Failure to pay will result in your account being referred to a collection agency, which may affect your credit. You must contact our billing office to discuss payment arrangements. NSF checks will result in a $25 processing fee.
No Show & Cancellation Policy
We require notification of cancellation for your appointment at least one business day in advance. Early notification helps us to fill the vacated slot in a timely manner. If proper notification is not given, this will be considered a No Show. After 3 No Show appointments, dismissal from the practice may be considered.