ADSCI

Dear Patient:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) created several guidelines for doctors to follow to encourage Electronic Patient Communication. A new requirement is the creation of a patient portal for doctor's offices to communicate safely and securely following Health Insurance Portability and Accountability Act of 1996 (HIPAA) guidelines.

Our office has an advanced Electronic Health Record (EHR) system that provides a patient portal called Patient Ally.

Please provide your email below so that we can enroll you in Patient Ally and assign you a temporary password. The temporary password is "DrLin123!". Please be sure to log in and change your temporary password at your earliest convenience.

Thank you for assisting us in fulfilling this important MACRA requirement.

Sincerely,

Dr. Lin

Thank you for choosing our medical practice. We are committed to providing you the best possible medical care. The following information is provided to avoid any confusion regarding payment for professional medical services. OurInsurance Billing Department will work with you to see that your claim is filed accurately and promptly.

• All Copayments and Deductibles must be collected in full at the time of service if applicable.
• If we are in-network with your insurance plan, we will not discount our services by any further amount after your insurance company has processed your claim and informed us of your responsibility.
• If we are not a contracted provider for your insurance company, we will bill them, as a courtesy, on your behalf.
• It is our preference to establish a credit card payment plan that we will use for settlement of all your account balances.

Optional: I authorize Advanced Dermatology and Skin Care Institute to charge outstanding balances on my account listed below after receiving a billing statement from the Billing Department:

• Please note: Unpaid account balances will be assessed a $10.00 re-billing fee for each statement generated after 90 days passed. Late fees will begin accruing after 90 days.
• If your account is overdue for more than 120 days after your insurance has paid, it will be referred to a collection agency. This is done reluctantly, as a last resort, after we have exhausted all efforts for voluntary payment.
• New Patients, and those who have no insurance, are required to pay at the time of service with either a credit card or cash. We do not accept personal checks.

Acknowledgement and Authorization

I have read, understood and agree to abide by the above payment policy. I understand that charges not covered by my insurance company, as well as copayment, deductibles and coinsurances, are my responsibility.

One-Time Authorization for Recipients:

Irequest that my payment of authorized Medicare benefits be made to me on my behalf to Michael T. Lin MD., Inc for any services furnished to me. I authorize holders of medical information about me to release to the Centers for Medicare & Medicaid Services and it's agents any information needed to determine these benefits or the benefits payable for related services. Additionally, I request that payment of authorized Medi-gap benefits be made to either me or on my behalf to Michael T. Lin MD., Inc. for any services furnished by this provider. I authorize any benefits or the benefits payable for related services.

By signing below, you agree to the Terms and Conditions of Advanced Dermatology and Skin Cancer Institutes Payment Policies:

ACKNOWLEDGMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES

Our office has copies of the HIPAA Notice of Privacy Practices available. Please feel free to get a copy or ask a staff member to hand one to you. I have read/understand the full Notice of Privacy Practices. read/understand the full Notice of Privacy Practices.

No Show Policy:

Please notify our office 48 hours in advance if you are unable to keep your scheduled appointment. If you do not notify us and miss your appointment by not showing up at all, we will require that you pay a $100.00 Missed Appointment Fee before any future appointments.

By signing below, I have read and understood the full Office Policy for No Show Patients.