Patient Information Record

Thank you for choosing Davis Dermatology.

We are glad you are here and look forward to a long lasting relationship.

If patient is under 18 yrs. of age please complete the following section

Previous Health History

Have you ever been diagnosed with or treated for the following problems?

Please check any item you would like more information about today

Patient Financial Policy Agreement

We are committed to providing you with quality healthcare and would appreciate your commitment to adhere to this Financial Policy Agreement. Please read this policy carefully and sign the Acknowledgement section at the bottom of this form. Please do not hesitate to ask a member of our staff if you have any questions.

For Medicare Recipients ONLY

I request payment of authorized Medicare benefits be made directly to Dr. Valerie G. Davis of Davis Dermatology for any services provided to me. I authorize the release of information to Medicare and my secondary insurance to assist me in the processing and payment of all claims. Dr. Valerie Davis agrees to accept Medicare assignment and I will be responsible for any deductible, coinsurance or any non-covered services determined by Medicare.

FOR ALL PATIENTS Insurance and Payment

1. All patients are required to provide a valid, current proof of insurance and a copy of your driver’s license. Failure to do so might result in denial of payment from your insurance plan and the balance will be your responsibility.

2. Payment of all deductibles, copays, coinsurances and other patient financial responsibilities are required at each office visit unless payment arrangements have been made in advance. *Your health policy is a contract between you and your insurance company and we are NOT a party to that contract.*

3. We will submit your claim and assist you in any reasonable way to help get your claim paid. It is your responsibility to provide your insurance company with any requested information in a timely manner. You are responsible for services that are NOT COVERED by your plan.

4. If we do NOT participate with your insurance plan, we will submit a claim to your insurance carrier as a courtesy to you but PAYMENT IS REQUIRED AT THE TIME SERVICES ARE RENDERED.

5. Self-Payment: Payment is expected at the time services are rendered unless prior arrangements have been made.

6. Medicaid: (if applicable) it is the patients responsibility that all proper authorizations have been obtained from your Medipass provider, otherwise payment is expected at the time services are rendered.

7. Care for minors: A parent or legal guardian MUST accompany minor patients on the patient’s first visit. The accompanying adult is responsible for payment of the account, according to the policy outlined above.

Note: This policy applies only to Davis Dermatology. Initial by both statements to signify understanding

• All lesions removed will be sent to a pathology lab.

• Payment for all non-medically necessary cosmetic services is expected at the time of the visit and will not be submitted to your insurance.

By signing below, I acknowledge that I have read, understand, and agree to the above Patient Financial Policy Agreement.

I authorize my insurance benefits to be paid directly to Dr. Valerie G. Davis and I also authorize the release of my medical information to my insurance company when required to facilitate payment of a claim.

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

Cancellation and No Show Fee Policy

Your appointment time is reserved especially for you and each time a patient misses an appointment without providing appropriate notice, another patient is prevented from receiving care. Please contact our office at 386-423-2218 no less than 24 hours prior to your scheduled office visit appointment time and 48 hours prior to a scheduled procedure/surgery appointment if you are unable to keep your appointment.

If you check in for your appointment more than 15 minutes past your scheduled appointment time, you may need to be rescheduled to the next available appointment time and date and the above no show policy will be enforced.

Davis Dermatology P.A. reserves the right to charge a $25.00 fee for all missed (Late Cancellation/No Show) office visit appointments and a $75.00 fee for all missed (Late Cancellation/No Show) procedure /surgery appointments.

These fees are not covered by your insurance carrier and must be paid prior to your next appointment. Multiple “no shows” or same-day cancellations in a six month period may result in termination from our practice.

We appreciate your understanding and cooperation as we strive to best serve the needs of all our valued patients.

By signing below, you acknowledge that you have received this notice and understand our practice's policy.

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