1. PURPOSE: The purpose of this form is to obtain your consent for a telemedicine consultation with a physician and/or healthcare provider. The purpose of this consultation is to assist in the diagnosis or treatment of your dermatology related condition.

2. NATURE OF TELEMEDICINE CONSULTATION: Telemedicine involves the use of audio, video or other electronic communications to interact with you, consult with your healthcare provider and/or review your medical information for the purpose of diagnosis, therapy, follow-up and/or education. During your telemedicine consultation, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio and telecommunication technology. Additionally, a physical examination of you may take place and video, audio, and/or photo recordings may be taken. Additionally, non-medical technical personnel may participate in the telemedicine consultation to aid in the audio/video link with the physician.

3. RISKS, BENEFITS AND ALTERNATIVES: The benefits of telemedicine include having access to medical specialists and additional medical information and education without having to travel outside of your local health care community. A potential risk of telemedicine is that because of your specific medical condition, or due to technical problems, a face-to-face consultation still may be necessary after the telemedicine appointment. Additionally, in rare circumstances, security protocols could fail causing a breach of patient privacy. The alternative to telemedicine consultation is a face-to-face visit with a physician.

4. MEDICAL INFORMATION AND RECORDS:  All laws concerning patient access to medical records and copies of medical records apply to telemedicine. Dissemination of any patient identifiable images or information from the telemedicine consultation to researchers or other entities shall not occur without your consent.

5. CONFIDENTIALITY: All existing confidentiality protections under federal and California law apply to information used or disclosed during your telemedicine consultation. 

6. RIGHTS: You may withhold or withdraw your consent to a telemedicine consultation at any time before and/or during the consult without affecting your right to future care or treatment, or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. If you are a Medi-Cal recipient and receiving teleophthalmology or teledermatology by store and forward, you have the right to interactive communication with the physician. This communication may occur at the time of your consultation or within 30 days after you receive the results of the consultation. 

My health care provider has discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I have read and agreed to a telemedicine consultation.

As required by HIPAA of 1996, you have the right to request that communication concerning your personal health information, be made through confidential channels. American Skin Institute will make reasonable efforts to accomodate all reasonable requests. Some method of contact must be provided in order to contact you with the results from labortory tests, biopsies, treatment recommendations, and payments.

I hereby request the use of the following communication channels for information related to my personal health, treatment, or payment for treatment. This request supersedes any prior request for confindential communications I have made.

Pursuant to Assembly Bill (AB) 1278, we are required to provide a notice to our patients regarding the Open Payments database (Database), which is managed by the U.S. Centers for Medicare & Medicaid Services, or CMS. I certify that I have received this written notice. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.

Thank you for choosing American Skin Institute to be your healthcare provider. Our team of medical professionals will strive to ensure the best possible outcomes for your care. Please take the time to review our financial policies below; this information is compiled with the intent to provide you comprehensive understanding of all the financial events that could impact your visit.

1. Consent to Treatment: I hereby authorize American Skin Institute, Inc. to provide medical services to me, and I hereby consent to the performance of laboratory  tests, diagnostics, and other medical treatments discussed with my physician.
2. Self Pay, Contracted & Non-Contracted Patients: If you do not have coverage by one of the insurance plans with which we are contracted, full payment for your services will be collected at the time of your visit. If at any time you are concerned about the cost of a procedure, you can speak with a representative from the billing office to better understand the costs associated with your visit. For your convenience in paying, we accept Visa, Mastercard, Discover, Care Credit, and Cash.
3. Insurance and Insurance Collection: American Skin Institute is contracted with Medicare and many other PPO health insurance plans; we do accept several HMO plans with a referral. Please call us to verify your HMO coverage. Based on the benefits provided by your insurance carrier, there may be a copay (office visit charge), deductible, and/or coinsurance that you are responsible for at the time of your visit. We will submit a claim to your insurance company on your behalf. Services that have been disallowed or non covered by your insurance carrier, are the responsibility of the patient. It may take your insurance company 30-60 days or longer to process your claim. Please remember that it is the patient's responsibility to understand what services are covered under his or her insurance plan and what benefits are provided.
4. Billing Process: A statement will be sent to the address on file for any charges outstanding or processed payments. Our billing office will work with you to understand any of these charges as needed. If your account is not settled in a timely fashion, your account will become delinquent and may be sent to collections.
5. Procedures and Lab Charges: If you have a skin growth or other specimen sent to a lab for evaluation, there will be two separate charges. One charge will occur for the performance of the procedure and another will occur for a lab to examine the specimen. The lab may independently bill your insurance carrier. If you have questions regarding these fees, please contact the lab that performed the services directly. General dermatology conditions can often require multiple treatments and there can  be no guarantee that a specific treatment will work for any specific condition. Multiple office visits may be required to determine an effective treatment. Each office visit will require a separate fee. If you have a copay, it must be paid at each visit per insurance company policies, we cannot waive copays or other patient financial obligations. The American Skin Institute reserves the right to send out specimens to an outside laboratory for special staining purposes, pathologic interpretation, and/or obtain a second opinion. The American Skin Institute is not responsible for any outside facility charges that be incurred.
6. Cosmetic Procedures: We do not bill insurance carriers for cosmetic procedures (lasers, peels, sclerotherapy, fillers, neurotoxins, Botox®, etc.) All cosmetic procedures must be paid in full prior to the procedure. Minimum cosmetic consultation fee is $150. Cosmetic consultation fee is non-refundable, and can be applied only to cosmetic procedures, not product purchases or any non-cosmetic medical services. Consult fee can be used only with the same provider seen for consultation. Payment is due at the time of service for all cosmetic procedures. Payment applies to the procedures performed at the time of service only and not to any other future treatments or packages unless specified in a written receipt at the time of payment.
7. Right to refuse service: You and the clinic have the right to refuse treatment at any time for any reason. 
8. Duration: This consent will be effective as long as you are a patient of this clinic.
9. Credit Card Payment Authorization: Medical charges are the responsibility of the patient. American Skin Institute will retain a credit card on file. As a courtesy to our patients, we will submit the charges for payments to your insurance company. We require credit or debit card information to be left on file for future balance billing purposes. Any remaining charges determined by American Skin Institute to be the responsibility of the patient, will be automatically charged to the credit card on file for your account. We accept all major credit cards, with the exception of American Express. 
10. Missed Appointments and Late Cancellations: We ask that you notify us at least 24 hours in advance of any cancellations to avoid incurring a fee. Otherwise, a $75 cancellation fee will apply for appointments cancelled or rescheduled within 24 hours of the scheduled appointment time. A $150 cancellation fee will apply for missed appointments including aesthetician services. Fees are higher for lasers, cosmetic, and surgical appointments.
11. Non Covered Services Are Your Responsibility: We may decline to see patients for non-emergent visits if co-payments are not made at the time of the visit. In addition, please be aware that your American Skin Institute physician may provide services that may not be covered as a benefit of your specific insurance plan. Patients or Guarantors are financially responsible for any and all services provided that may not be covered by your insurance plan. It is your responsibility to know and understand your specific insurance plan and what benefits are provided. Some procedures you may undergo are best performed utilizing the equipment, safety, and comfort that can be obtained in an Ambulatory Surgery Center (ASC) setting. Please be aware that these charges are separate and apart from those fees charged by the physicians of the American Skin Institute. You should ask your insurer how your benefit plan would cover any outpatient facility/ASC charges.
12. Minor patients: The adult accompanying a minor and the minor's parents or guardians are responsible for full payment for services rendered. If a minor is unaccompanied, consent for treatment and payment arrangement must be provided in advance of treatment. Payment may be by pre-authorized credit card, payment on account in advance, or check or credit card present at the time of service.

 

I authorize the American Skin Institute to conduct examinations, and perform procedures as are medically required to administer treatment and medication as deemed necessary or advisable.

American Skin Institute is hereby authorized to release a complete report of services rendered, diagnosis, findings, and details of treatment and progress for the purpose of receiving payment for such services rendered. Recipients of such information may include: authorized billing agents, insurance carriers, employer's worker's compensation insurance company, other third party payers, the Social Security Administration under Title XVII (18) of the Social Security Act, Professional Review Organizations, or other Intermediaries responsible for payment of services rendered. The release of information consent may be revoked at any time by giving written notice.

If release of information is refused, the patient will be held responsible for payment of all charges for services rendered. In consideration of medical goods and services provided by the American Skin Institute, I give all rights, title, and interest to the medical/surgical/supply reimbursement in accordance with the terms and benefits of the patient's insurance policy or other health benefits including Medicare Part B. I remain fully responsible for payment of any and all charges not covered by insurance or Medicare.