Please include brand and dosage of birth control on the medication list (next page).
As required by HIPAA of 1996 you have the right to request that communication concerning your personal health information be made through confidential channels. Orange County SkinLab will make reasonable efforts to accommodate all reasonable requests. Some method of contact must be provided in order to contact you with results from laboratory tests, biopsies, treatment recommendations and payments. I, First Name* Last Name* (print full name) 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 confidential communications I have made.
If you are unavailable, Orange County SkinLab has permission to speak with Name and Contact information
Patient Acknowledgement and Authorizations
This form is required to allow us to evaluate and treat you, and to bill and communicate with your insurance
I authorize Orange County SkinLab to conduct examinations, and perform procedures as are medically required to administer treatment and medications as deemed necessary or advisable.
Orange County SkinLab 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 workers' compensation insurance company, other third party payers, the Social Security Administration under Title XVIII (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 Orange County SkinLab. 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.
Patient Assignment of Benefits
This form is required to allow us to bill and accept direct payment from your insurance company or other payer.
Orange County SkinLab will bill all primary and secondary insurances, but I am ultimately responsible for payment for the services and any supplies/equipment I receive.
I hereby assign to Orange County SkinLab any insurance or other third party benefits available for healthcare services provided to me. I understand that Orange County SkinLab has the right to refuse or accept assignment of such benefits.
If these benefits are not assigned to Orange County SkinLab, I agree to forward to Orange County SkinLab all health insurance and other third party payments that I receive for services rendered to me immediately upon request.
I understand that my signature requests that payment be made directly to Orange County SkinLab. I authorize release of medical information necessary to pay the claim. A photocopy of this assignment is to be considered as the original.
I have read and agree with the above Patient Acknowledgement and Authorizations and Patient Assignment of Benefits. I understand the terms and conditions outlined herein as confirmed by my signature below.
*NOTICE: If patient is a minor (under 18 years of age) the parent of responsible party must complete and sign the Consent for Treating of Minor Form.
Thank you for choosing Orange County SkinLab, as a healthcare provider. We are committed to your treatment being a successful experience. Our Medical and office staff will work very hard to make sure that your paperwork is filed accurately and promptly. Because most of the data we have comes from you, please help us maintain accurate records by letting us know whenever important data changes (your address, telephone number, any changes to your name, your medical insurance, etc when paying for services, supplies, etc. We are able to accept all major credit cards, checks and cash.
Insurance and Insurance Collection
We will attempt to bill whichever insurance you have advised us of as a courtesy. Please understand that insurance reimbursement can be a long and difficult process for medical providers AND patients. There are instances when insurers will stall,deny, pend, spend weeks and months reviewing claims, and then reduce or deny any reimbursement officered. Our billing company has undergone extensive training to maximize your insurance reimbursement while reducing the time in which they
Non-Contracted indemnity insurance plans/No insurance card
If you are unable to present an insurance card at the time of service, or if you are covered by an insurance company with which we are not contracted, we require that you pay for services in advance. If we are able to collect from your insurance company after you have fully paid your account, we will issue you a refund. We will attempt to bill your insurance company using the information you have supplied to us as a courtesy. Our office, as a convenience and a service to you, will absorb all costs incurred for this billing. Please note that not all insurers agree to contract with us. In the event that your insurance does not reimburse us within ninety (90) days, we will transfer this balance to you as your responsibility and send you a statement. We are NOT Medi-Cal providers, and do not accept Medi-Cal. We do not accept any other State's Medicaid programs. At the current time, we are not within the network for Covered California or Affordable Care Act coverage.
Know Your Plan Benefits - Non Covered Services are Your Responsibility
Each and every insurance company and plan, including Medicare, has different plans, each with different benefits. Because your health insurance is an arrangement between you and your insurer, you should understand what services are covered under your specific plan. Your insurer can assist you with any questions you have relative to your own benefits with them. Co-payments are due at the time of service. You should ask your insurer what the amount is and have it ready at the time of your visit. We may decline to see patients for non-emergent visits if co-payments are not made at the time of the visit. Orange County SkinLab may provide services that may not be covered as a benefit of your specific plan with your insurer. 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 will involve removing tissue. The charges for this process are known as Laboratory/Pathology charges and will appear on your bill if performed. The physician who looks at the slide and provides her opinion based on those slides is known as the Dermatopathologist (Dr. Hure). There is a charge for her professional opinion, which is independent of the charge for preparing the actual slide or taking the biopsy.
As a contracted provider, Orange County SkinLab has agreed to accept a discounted rate from your plan for covered services, however all co-payments, co-insurance and/or deductibles are your responsibility and will be collected on the day of service.
As a participating provider, we will bill your Medicare carrier. You are responsible for your annual deductible and 20% of the co-insurance portion. We must collect this. We will be happy to bill any secondary (or Tertiary) insurance you may have once we have been informed that you have such coverage in effect. If any balance remains once Medicare and these insurers have processed our claims, we will transfer responsibility for payment to you, and send you a statement.
Important reminder for Medicare enrollees: If you qualified for Medicare coverage and decided to enroll in a managed Medicare+Choice/Medicare Advantage plan (e.g. MemorialCare, Blue Cross Senior Secure, SCAN) you are not eligible to be seen at Orange County SkinLab unless you choose to be a cash patient
Having more than one insurance does NOT necessarily mean that your services are covered 100%. Depending on your plan's benefits, the secondary insurers will pay as a function of what your primary insurer pays. We will bill your secondary insurer as a courtesy. You are responsible for any balances after your insurers have processed our claims.
Orange County SkinLab is NOT a party to any divorce decree. Adult patients are responsible for their bill at the time of service. The responsibility for minors rests with the accompanying adult.
The adult accompanying a minor and the parents (guardians) of the minor are responsible for full payment for services rendered to the minor patient. For unaccompanied minors, non-emergent or treatments unrelated to an ongoing care plan, will be denied unless charges have been pre-authorized to an approved credit plan, credit card, or payment by cash or check at the time of service has been obtained or verified.
Return Check Fees
There is a $25.00 banking fee for all returned checks. This sum is used to offset the fees incurred by OC SkinLab from our financial institution. If your check is returned from the bank, we may NOT ACCEPT an additional check as payment on your account. Future payments must be made with cash, money order or credit card.
Orange County SkinLab will send you a statement after your insurers have been billed and your insurers have considered your charges. We will charge interest of 1.5% (18% annually) on all outstanding balances after 30 days. If no payment is received after 120 days, your account may be turned over to a collections agency and a $25.00 late payment/pre-collection fee will be added to your account to offset the administrative costs incurred when accounts are assigned for collection.
Completion of all forms will require a Telemedicine visit and incur the appropriate visit fee.
Records and Copying
(First complete and sign a Release of Records from authorizing us to release your records. We cannot begin the process without this documentation.)
There is no charge for electronic faxing of records. If paper copies are requested, a charge for copying medical records will be incurred. There is a fee of .25 cents per page printed, plus, reasonable clerical fees of $24.00/hour (charged in quarter hour increments), which includes the time spent in locating the records plus postage fees. The records will not be sent until the fee is paid. These fees are set by the State of California (Health & Safety Code section 123110), not Orange County SkinLab.
No-Shows and Cancellations
Patients who fail to show ("no-show") at their initial office or telemedicine visits without appropriate notice will not be allowed to rebook for future appointments. Patients who cancel within 24 hours of the scheduled appointment will not be allowed to rebook after the third occurrence. All patients who fail to show or cancel within 24 hours of their appointment time will be subject to a late cancellation/"no-show" fee of $75.
Thank you for your time in understanding the financial policy of the Orange County SkinLab. It is our desire to serve your medical needs as well as we possibly can. By understanding the financial policy we utilize, we can make billing a non-issue and concentrate on providing you with the best possible care and treatment. All patient information is confidential and subject to state laws including Confidentiality of Medical Insurance Act Section 56 of the California Civil Code and the Health Insurance Portability and Accountability Act (HIPAA)
I have read and agree with the Patient Financial Policy. I understand the terms and conditions outlined herein as confirmed by my signature below.
I hereby acknowledge that I was offered and/or received a copy of Orange County SkinLab's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that a copy of any amended Notice of Privacy Practices will be available at each appointment. Any questions regarding the Privacy Practices of the Orange County SkinLab should be directed to Dr. Hure at firstname.lastname@example.org.
Card Number 1-4* 5-8* 9-12* 13-16* Expiration Date MM/YY* CVV *
I, First Name* Last Name* , authorize Orange County SkinLab to charge my credit card above for agreed upon purchases, including but not limited to co-payments, co-insurance, deductibles, patient balances, and no-show fees. I understand that my information will be saved to file for future transactions on my account.
Given the current pandemic induced by the SARS-CoV-2 and COVID-19 (the respiratory illness induced by the virus), we strongly urge you to learn more about COVID-19 at the Center for Disease
As you may know, our practice is dedicated to skin cancer and skin health. We want to assure you that our priority is your health and safety, as is the health of our staff and their loved ones. For this reason, we have immediately implemented all of the CDC recommendations in terms of preventing and limiting the potential exposure to the coronavirus in all aspects. Current protocols include, but are not limited to, thorough prescreening of patients for COVID-19 symptoms and known contacts, strict masking of patients and full PPE precautions of staff, air purifiers, sanitizing of exam rooms and surfaces after every encounter, temperature screening prior to entry and scheduling of appointments to allow ample time between patients. However, despite our best efforts to sanitize our office and protect you and us from the viral transmission of this virus, your visit with us may expose you to the
While much is known about the virus and the illness it causes (COVID-19), there is much still that remains unknown. Per the CDC states, "People are thought to be most contagious when they are most symptomatic (the sickest Some spread might be possible before people show symptoms; there have been reports of this occurring with this new coronavirus, but this is not thought to be the main way the virus spreads."
Therefore, you, people who you are in close contact with, as well as one of us, or someone with whom we are in close contact with, may be carriers and expose all of us to unforeseen risks. The doctors interact with many patients, as do our staff, and some of our staff have family members who are also health care professionals.
By signing below, you are expressly acknowledging that your care with Dr. Michelle Hure, as well as your interaction with our medical and administrative staff here at OC SkinLab may be exposing you (or one of your loved ones) to COVID-19 which may be mild or may be severe and may cause death. Your signature expressly releases the doctors and staff at OC SkinLab of any and all liability, sickness, loss of work, or other unforeseen damages/injuries as a result of COVID-19 to you or anyone with whom you are in close contact. In addition, any patient or accompanying family member who enters our facility without disclosing known COVID-19 symptoms and/or exposure with known COVID-19 contacts or refuses to wear a proper mask will be discharged from the practice.
We do not wish to add additional stress to your visit to us. We must, however, be open and honest in our communication to you about real or potential, unforeseen, as well as theoretical risks associated with your care at OC SkinLab during this pandemic.