OFFICE FINANCIAL POLICY:
PAYMENT AT TIME OF SERVICE: Payment for our services is due at the time of your visit. This includes co-pay, co-insurance, non-covered services, and payment to meet your insurance deductible.
INSURANCE: Patients will be asked to present their insurance card to the receptionist for copying upon check-in at the office each time they are seen for medical services. Please make it a point to bring your insurance card with you each time that you visit our office. It is the responsibility of the patient to provide accurate insurance and personal information including any preferred laboratory cards. If your insurance requires a referral, it is your responsibility to provide the referral prior to your visit. You will be responsible at the time of service for the payment of copays, unpaid deductibles, and past due balances.
For those patients covered by insurance plans with which we ARE participating providers, all co-payments, deductibles and noncovered services are due at time of service. We will file the insurance claim to the insurance company. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service and we will file your claim to the insurance company as a courtesy. Any charges that are not paid by your insurance company are your responsibility. Your insurance policy is a contract between YOU and your insurance company. Any pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this.
COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency.
CANCELLATIONS and MISSED APPOINTMENTS: We understand that unexpected events, illnesses, etc occur. When this happens, call our office as soon possible to inform us of such issues. In the case of missed appointments or cancellations within 24 hours of the appointment:
-Office Visit- I understand that it is my responsibility to cancel my appointment 24 hours in advance of my appointment time.
Credit Card Authorization (Credit Card on File): I authorize Dr Del Campo and Chicago Skin Clinic to charge my credit card above for agreed upon purchases, procedures, missed appointments, or services. I understand that my information will be saved to file for future transactions on my account. My information will be stored in bank level security using Square. This authorization will remain in effect until cancelled.
AUTHORIZATION & AGREEMENTS OF MEDICAL TREATMENT
CONSENT FOR EXAMINATION: I understand that an examination will be necessary and I consent to the partial or complete examination as part of my medical care. I understand that the examination findings will be provided to me with recommendations. The responsibility for any follow-up examination to check abnormalities found and treated, lies with me and not Chicago Skin Clinic, or assistants. I hereby release my examiner from all responsibility in connection with the examination.
CONSENT FOR TREATMENT: I hereby consent to and authorize the administration of all diagnostic and therapeutic treatments, including biopsies and cryosurgery, that may be considered advisable or necessary in the judgment of Chicago Skin Clinic. No guarantee or assurance has been given by anyone as to the results that may be obtained by such treatments.
In order to fulfill our commitment to be as accessible as possible to our patients, we seek your permission to communicate with you via the most convenient means possible, using the communication tools you use every day.
CONSENT FOR ELECTRONIC COMMUNICATION: I hereby consent and state my preference to have my physician and other staff at Chicago Skin Clinic communicate with me by email AND standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, billing statements, and informational marketing. I understand that email and standard SMS messaging are not secure methods of communication. I further understand that, because of this, there is a risk that email and standard SMS messaging regarding my medical care might be intercepted and read by a third party.
CONSENT FOR INFORMATION LEFT ON VOICEMAIL: I hereby consent that telephone messages regarding my appointments, prescription renewals, lab results and all protected health information may be left for me on my voicemail and/or answering machine. I hereby consent that the phone number provided by me to Chicago Skin Clinic is accurate and up to date.
CONSENT FOR PHOTOGRAPHY:I hereby consent that Chicago Skin Clinic can take my photograph to incorporate into my electronic medical record. This photograph is used for medical purposes (to be used by all medical providers at Chicago Skin Clinic) and will be stored in the medical chart under encryption. I understand that a photographic image will be taken of any biopsy or surgery site performed or any cosmetic procedure performed for the sole purpose of identification of said site, insurance claims, and treatment progression. I expressly consent to having said photograph taken.
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:
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 have the right to review this facility’s notice prior to signing this authorization. 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:
Teledermatology Consent Form:
In light of the COVID-19 pandemic, we are making every effort to ensure our patients are able to receive access to medical services. We are thrilled to be able to offer telemedicine services to you in this emergency situation. However, we want to be fully transparent and make sure that you understand there are certain inherent limitations and risks associated with telemedicine. For example, there may be interruptions or technical difficulties, or the transmitted information may not be sufficient.
In the event services are being provided through a third-party platform that has not been developed specifically for providing telemedicine services (e.g., Facetime), please understand that such platforms are encrypted and secure but may not provide HIPAA compliant security measures. Please keep in mind that communications via popular email services (e.g. Gmail, Hotmail, Yahoo, Aol) do not utilize encrypted email. Although it is unlikely, there is a possibility that information sent in an email can be intercepted and read by other parties besides the person to whom it is addressed. By communicating to your medical provider through such platforms, you acknowledge your recognition and understanding of the inherent risks and consent to communications Facetime, Google, and/or the use of unencrypted emails despite those risks. through
1. PURPOSE: The purpose of this form is to obtain your consent for a telehealth visit with your dermatologist, Dr. Del Campo, at Chicago Skin Clinic. The purpose of this visit is to help in the care of your skin problem.
2. HOW TELEHEALTH WORKS: In a telehealth visit, you will interact in real time with your dermatologist via a secure, online videoconferencing technology. Your dermatologist has the right to discontinue videoconference should the connection or the forwarded image be of poor quality. The dermatologist will look at the patient’s skin during a videoconference or review the photos you submitted. The dermatologist will then give you advice about your dermatologic condition and how to treat and take care of your condition. The information from the dermatologist will not be the same as a face-to-face visit because the dermatologist is not in the same room. Sometimes a face-to-face follow-up visit with the dermatologist may still be needed. If you do not come into the office for an in-person visit, the dermatologists’ advice will be solely based on the viewing your skin condition during videoconference and/or additional electronic images provided. In the absence of an in-person physical evaluation, the dermatologist may not be aware of certain facts that may limit or affect his/her assessment or diagnosis of your condition and recommended treatment. It is possible that there will be errors/ deficiencies in the transmission of the images of your skin condition during videoconference or about your condition. in the photos submitted electronically that may impede the dermatologists’ ability to advise you
3. MEDICAL INFORMATION AND RECORDS: All federal and state laws covering access to your medical records (and copies of medical records) also apply to telehealth. No one other than the health care team described above can view your photos or information unless you agree to give them access.
4. PRIVACY: All information given at your telehealth visit will be maintained by the doctors and health care facilities involved in your care and will be protected by federal and state privacy laws.
5. YOUR RIGHTS: You may opt out of telehealth visits at any time. This will not change your right to future care or health benefits.
6. FINANCIAL RESPONSIBILITY: Please understand that payment of your bill is considered part of your care plan. In light of the COVID-19 pandemic, we are providing telemedicine services. CMS and many private insurers are working to make such services more broadly available to their patients. In turn, we are making our best effort to provide you services through the currently available platforms.
In connection with these services we will bill your insurance for telemedicine visits in the same manner as in-person visits. Although we have made efforts to ensure payment will be provided by your insurance, we highly encourage you to contact your carrier to understand the details/rules of your health plan(s) and what services are covered by your specific plan. Insurance plans vary considerably, and we cannot predict or guarantee what part of our services will or will not be covered by your plan.
Estimated patient responsibility will be collected prior to start of the telemedicine encounter. It is your responsibility to supply all current insurance cards and identification. Final patient responsibility will be determined after charges are filed and processed by your insurance carrier(s By signing this consent form, I hereby acknowledge I have read and understood my financial responsibility and agree that payment for the care I receive is ultimately my responsibility. In the event, my insurance does not provide reimbursement for the telemedicine services I receive, I am responsible for the costs of this service and any associated copays, coinsurance and deductibles. Self Pay charge for telemedicine service is $95.
7. WAIVER/RELEASE: By signing below, you understand and agree that you solely assume the risk of any errors or deficiencies in the electronic transmission of information during your telehealth visit or in the electronic submission of your images to your dermatologist and further understand that no warranty or guarantee has been made to you concerning any particular result related to your condition or diagnosis. To the extent permitted by law, you also agree to waive and release your dermatologist, staff and Chicago Skin Clinic from any claims you may have about this advice or the telehealth visit generally. The consent provided in this document will expire in one year from the date you sign it, but your waiver and release shall apply indefinitely for any telehealth visits that occur after your signature date.
Wonderful! Thank you for your asssitance!
You can call us at 773-286-8111 or visit us online at ChicagoSkinClinic.com
We look forward to your upcoming visit with us at:
5440 W. Belmont, Chicago IL 60641