***We try our best to be punctual and courteous of your time and the time of our other patients. For this reason we are only able to address a maximum of two issues per visit. We will schedule you for a follow-up appointment for additional evaluation if necessary.***

Thank you very much for trusting us with your care. It is our policy to require patients to have a credit card on file. We will be asking for your credit card when you arrive for your appointment. The reason we require the credit card is (1) for unpaid bills and (2) to cover our "no show" fee. Many patients have high deductible plans, or do not understand their responsibilities for payment, and simply do not pay us for the services we provide. In addition, on average, between 5% and 10% of our scheduled patients do not attend their appointments without providing advanced notice to us. 

 

Although you may have excellent insurance and are most likely very diligent about attending your appointments, or providing notice, we must apply our office policies consistently to all patients. Please be assured we would never charge a credit card inappropriately, and it is always the right of a cardholder to dispute a charge. 

 

Please further understand that it has become exceedingly difficult for individual, small practices like Kirsch Dermatology to operate. These policy changes are necessary to ensure the ongoing viability of our office. 

If your insurance is an HMO plan, we will need a referral from your primary care physician prior to your appointment.

*Insurance is not a guarantee of payment.

I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I authorize payment of these benefits to Kirsch Dermatology on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer of agency shown and authorizes my doctor to act as my agent, as above.

PRIOR AUTHORIZATIONS:
Kirsch Dermatology will complete prior authorizations for medications if the out-of-pocket cost exceeds $100. We cannot complete prior authorizations if the cost is less than $100 due to the excessive administrative burden this places on our practice. Thank you for your understanding.

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment;
• a means of communication among the health professionals who may contribute to my healthcare;
• a source of information for applying my diagnosis and surgical information to my bill;
• a means by which a third-party payer can verify that services billed were actually provided;
• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

HIPAA PRIVACY RULE OF PATIENT CONSENT AGREEMENT

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

• I have the right to review this facility’s Notice of Information practices prior to signing this consent;
• This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested;
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

HIPAA Contact Consent:

*Do you authorize medical information regarding your care such as test results, appointments, billing information, etc. to be shared with someone other than yourself? (If the authorized person/organization is not a healthcare provider, they may further disclose the protected health information and it may no longer be protected by the federal health information privacy laws.) EXAMPLE: Spouse or Family member.

You may revoke this consent at any time in writing once signed. The person/persons named MUST give Kirsch Dermatology staff your full name and date of birth in order to receive any information. 

I voluntarily consent to the rendering of care, including treatment, administration of anesthetics and performance of diagnostic and/or surgical procedures. I understand that I am under the care and supervision of Kirsch Dermatology.

I further consent to the examination for diagnostic, investigational purposes, and disposal by authorities of the above-named medical facility or it designates herein, of any tissue or parts which may be removed. I understand that the skin biopsy involves removal of a piece of skin and that such removal may result in a permanent scar or in discoloration of the skin at the site of the biopsy. I further understand that more than one biopsy may occur during this visit.

I understand that all specimens removed are sent for pathologic analysis and that the charges for pathology will be billed to my insurance. However, I understand that in certain cases, I may be responsible for a portion or all of the charges.

I understand that Kirsch Dermatology will take a photo/photos of any biopsies, possible monitoring sites or any suspicious sites; used only for diagnostic purposes.

I consent for medical photographs to be used by the staff or representatives of Kirsch Dermatology. I understand that the images will be placed in my medical record and may be used for evaluation by employees of Kirsch Dermatology. By consenting to the use of these medical photographs, I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. I also give permission for transfer of these photographs via a non-encrypted email exclusively for the purposes of third-party diagnostics, treatment, and continuing medical care (e.g. communication with my primary care physician).

If I wish to withdraw my consent in the future, I may do so with a written request.

Kirsch Dermatology has/will explain to the me/my family/my guardian the nature of my condition, the nature of the procedure, and the benefits to be reasonably expected compared to alternative approaches. Kirsch dermatology has/will discuss the likelihood of major risks or complications of this procedure including specific risks and (if applicable) drug reactions, hemorrhage, infection, and or complications. Kirsch Dermatology has also indicated that with any procedure that there is also the possibility of an unexpected complication.

MEDICATION HISTORY: Patient medication history is a list of prescription medicines that our practice providers, or other providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The medication history may include sensitive information including, but not limited to, medications related to mental health conditions, sexually transmitted diseases, substance (drug and alcohol) abuse and HIV/AIDS.
Obtaining your medication history is very important in helping healthcare providers treat you properly and in avoiding potentially dangerous drug interactions. Please note that some pharmacies do not make drug history available. Your drug history may not include drugs purchased without using your health insurance as well as over-the-counter drugs, supplements, or herbal remedies that patients take on their own.
By signing this consent form, you are giving your healthcare provider permission to collect information about your medication history, and it gives permission to your pharmacy and your health insurer to disclose your medication history. This includes specific consent to release sensitive health information listed in the first paragraph.

FINANCIAL POLICY

INSURANCE: Patients must present with the proper insurance documents at the time of service in order for KIRSCH DERMATOLOGY to properly file claims in a timely fashion. If the necessary information is not received in a timely fashion, KIRSCH DERMATOLOGY will not be responsible for denials and/or patient balances as a result. Patients are responsible for maintaining active coverage, obtaining proper referrals, confirming their provider’s participation in the network and their own familiarity with the benefit package therein. KIRSCH DERMATOLOGY reserves the right to collect copays and estimated patient liability at the time of service in line with the current insurance carrier contracts.

AUTHORIZATIONS: The patient understands that all surgical cases are authorized by the KIRSCH DERMATOLOGY prior to the scheduled surgical date. The authorization process can take up to 45 business days per insurance contracts and guidelines. The patient understands that if approval is not obtained three (3) weeks prior to the surgical date, the patient must elect to reschedule or move forward as a self-pay/cosmetic patient.

OUTSIDE CHARGES: The patient understands that there may be additional outside charges for covered services such as laboratory, pathology, facility and anesthesia when applicable. The patient understands that KIRSCH DERMATOLOGY is available as a resource when problems arrive, but balances related to outside services must be addressed directly with the billing entity

ASSIGNMENT OF BENEFITS AND FINANCIAL RESPONSIBILTY: The patient hereby assigns all medical and/or surgical benefits from Medicare, private insurance and any other health plans to: The KIRSCH DERMATOLOGY. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

The patient hereby authorizes said assignee to release all information necessary to secure the payment. The patient authorizes KIRSCH DERMATOLOGY to release any information acquired in the course of my exam or treatment to their insurance company, primary care physician, pediatrician or another physician. The patient recognizes that they are responsible for all charges incurred whether or not paid by their insurance company. They also recognize and agree that they will pay any amount not paid by their insurance company within 30 days. In the event the patient fails to comply with this financial policy, they understand that their account may be turned over to a collection agency. The patient understands and agrees that, they are ultimately responsible for the balance on the account for any professional services rendered. The patient agrees to notify the KIRSCH DERMATOLOGY of any changes in their health status or health insurance. If the patient is a member of an HMO or PPO group and the insurance company has not paid the claim within 90 days of the visit, the patient understands they are responsible for the balance due.

FINANCIAL HARDSHIP: KIRSCH DERMATOLOGY recognizes that patients may experience financial hardship from time to time, which prohibits them from paying their bills in a timely fashion. At its discretion, Kirsch Dermatology may offer reductions for patients that present for medically necessary procedures without insurance. Requests will be reviewed individually after being submitted in writing.

CREDIT CARD ON FILE: It is the policy of the KIRSCH DERMATOLOGY to keep a credit card on file for patient balances. All outstanding balances for patients after insurance processing or for self-pay charges not collected at the time of service (for any reason), will be charged at the beginning of the following calendar month. By agreeing to this policy, you are acknowledging and agreeing to have your card on file charged for any outstanding balances on a rolling monthly period. Our patients are acknowledge that they will receive three statements to the mailing address on file, then we may charge the credit card we have on file.

RETURNED CHECK POLICY: A $50.00 service charge will be levied on all checks returned due to insufficient funds or for any other reason. This will be added to the original check amount.

COVERED SERVICES: All cosmetic services are not covered by insurance and must be paid in full. If a patient decides to move forward cosmetically, they do so with the understanding that KIRSCH DERMATOLOGY will not accept assignment of benefits, nor will the KIRSCH DERMATOLOGY submit for coverage thereafter or assist in the patient submission process.

COSMETIC NO SHOW FEES: Cosmetic consultations carry a $100.00 non-refundable charge at the time of booking. This fee is applicable towards the total cost of the patient’s surgical treatment should they chose to schedule. In the event that a patient does not cancel their appointment with notice and “no-shows,” the deposit fee will be kept as a penalty.

SURGICAL DEPOSIT/PRE-PAYMENT: Patients that wish to book and hold a surgical date are required to pay a non-refundable deposit of $500.00, which is applicable towards the total cost of the surgery. This deposit is not transferrable to any other date of service if surgery is rescheduled. Payment in full must be received at least two (2) weeks prior to the scheduled surgical date. Your surgical date and deposit will be forfeited at that time in the event payment is not received.

REFUND POLICY: KIRSCH DERMATOLOGY makes every attempt to accommodate patients that need to reschedule. However, late cancellation often results in lost surgical scheduling time for KIRSCH DERMATOLOGY and as such do carry a fee as follows (does not include deposit):
- Cancellation within two (2) weeks of surgical date: 30% of total surgical fees forfeited.
- Cancellation within forty eight (48) hours: 50% of total surgical fees forfeited.

***As much as we dislike asking patients to sign credit card forms and cancellation policy forms, it is an unfortunate necessity in this age of high deductible plans and missed appointments.***

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, patients who do not show up for their appointment without a call to cancel at least 24 hours before the appointment time will be considered as NO-SHOW.

Kirsch Dermatology has the right to charge a fee of $50.00 for all missed appointments ("no shows")."No Show" fees will be billed to the patient. This fee is not covered by insurance and must be paid in full prior to your next appointment. Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.

By signing below, you acknowledge that you have received this notice and understand this policy.