Acknowledgement of Receipt of Notice of Privacy Practices

I have received a copy of Hunterdon Dermatology, LLC’s Notice of Privacy Practices.
I may refuse to sign this acknowledgement.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Authorization Section

Authorization to Pay Benefits to Physician:

I hereby assign payment directly to the Physician for the Surgical and/or Medical benefits, if any, otherwise payable to me for services as described but not to exceed my indebtedness to Physician for those services. I understand I am financially responsible for charges not covered by my insurance. I further authorize:

Authorization to Release Information:

I hereby authorize the Physician to release any information acquired in the course of my examination or treatment to my referring physician and/or to my insurance carrier information needed to determine benefits.

Acknowledgement of Out of Network Status:

I understand that Hunterdon Dermatology, LLC does not participate with medical insurance providers beyond standard Medicare. Anything other than standard Medicare coverage, will be considered out of network and I will be financially responsible for payment of charges incurred.

A photostatic copy of this authorization shall be considered as valid as the original. This authorization may be revoked by me in writing.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.