New Patient Registration Form

Please correct the errors described below.

INSURANCE INFORMATION

We are are a direct pay practice and are therefore out of network with most insurance plans. However, we collect insurance information in the event that we go into network with insurance companies or are contacted by insurance companies pertaining to claims filed by you for your care here and need to help them verify your care. Please note that we are currently not accept patients receiving any kind of government-backed insurance plans for medical (but not cosmetic) services, including Medicare, Medicaid, and TriCare although this may change in the future.

** If secondary or tertiary insurance does not apply to you, then you may leave those blank.

Primary Insurance Policy Holder's Name (if different from patient or responsible party)

Secondary Insurance Policy Holder's Name (if different from patient or responsible party)

Tertiary Insurance Policy Holder's Name (if different from patient or responsible party)

If patient is a minor please enter responsible party information. (Note: We do not bill absent parents, the adult presenting the minor for care is the responsible party.)

PATIENT FINANCIAL POLICY

All Dermis Dermatology, PC
I understand that All Dermis Dermatology, PC is a direct pay practice. Your fees are only for services performed at or by our practice and are due at the time of service, although an advance deposit may also be required. There may be other fees associated with pathology, lab work, or other related medical care not affiliated with our office, and you will be directly billed by the outside providers for such components of your medical care. However, it is ultimately the responsibility of the patient/guarantor to determine if All Dermis Dermatology, PC is a participating provider.

If we have a contract with your plan, we will file a claim with your insurance company. The amount for which you are responsible (any deductibles, copay's, percentages or non-covered services) is required at the time of service. If arbitrary determination of a participating insurance company determines that services are cosmetic or not medically necessary, the patient/guarantor will be responsible for the outstanding balance. If you do not have one of the plans with which the practice is contracted, the total cost of your visit is required at the time of service. If at any time you are concerned about the cost of a procedure proposed by the doctor, you may ask for someone from the business office who will be happy to discuss the cost with you.

Payment in full is expected on outstanding balances. In the course of outstanding balances, two statements will be generated, after which, notice prior to collections will be mailed. If a payment plan is necessary, terms and conditions will be determined solely by All Dermis Dermatology, PC, not by the patient/guarantor. There will be a 50% charge added to the outstanding balance due plus required postage if the debt is referred to a collection agency for collection. If legal action is necessary, the associated fees assigned will be added to the fees incurred from medical treatment. Printing of any records for legal, life insurance, personal, or other reasons will be $50 to cover labor and supplies based on the number of pages provided.

For your convenience in paying, this office accepts Master Card, Discover, and Visa in addition to cash and checks. There will be a $50 fee for any returned checks.

Because we make every effort to see patients on time, we do not overbook to accommodate patients who do not keep their appointments. Therefore, when less than one business days' notice is provided, there will be a $50 charge. If cancelling, please do provide us notification as early as able so that another patient can utilize your reserved spot.

Any person signing this document as a “guarantor” agrees to payment and fees as described above for the patient noted below. I certify that I have read the financial policy of All Dermis Dermatology, PC, and agree to abide by the policy.

I authorize my insurance company to pay benefits on my behalf directly to All Dermis Dermatology, PC. I authorize All Dermis Dermatology, PC to provide to my insurance company any information necessary to process claims for services rendered to me.

MEDICARE
If I have Medicare insurance, I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply.

MEDIGAP
If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier automatically “crosses over”, we are required to keep a separate signature on file:

If I have MEDIGAP insurance, I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to my MEDIGAP carrier any information needed to determine these benefits or the benefits payable for related services.

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.

OPTIONAL CREDIT CARD INFORMATION

CREDIT CARD AUTHORIZATION
Optional, Non-required Convenience

If you have ever checked into a hotel or rented a car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage for both you and the hotel or rental company, since it makes checkout easier, faster, and more efficient. We have implemented a similar policy. You will be asked for a credit card number at the time you check in and the information will be held securely until your insurances have paid their portion and notified us of the amount of your share. At that time, any remaining balance owed by you will be charged to your credit card, and a copy of the charge will be mailed to you. This will be an advantage to you, since you will no longer have to write out and mail us checks. It will be an advantage to us as well, since it will greatly decrease the number of statements that we have to generate and send out. The combination will benefit everybody in helping to keep the cost of health care down.

This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment. Co-pays due at the time of the visit will, of course, still be due at the time of the visit.

If you have any questions about this payment method, do not hesitate to ask. Any charges over $100 will be additionally verified and approved by you via phone or other method before processing.

I authorize All Dermis Dermatology, PC, its Doctors, and/or staff to issue charges to my credit card account (shown below) under the following circumstances:

I understand that I am responsible for payment of the following charges at the time of service: deductibles, services not covered by my insurance policy, medically unnecessary/cosmetic services, co-payments, and insurance balances from previous appointments (should my primary insurance be with a company with which All Dermis Dermatology, PC Cancer & Dermatology is contracted).

If my insurance company is not one with which All Dermis Dermatology, PC is contracted, I am responsible for the entire amount of charges at the time of service. I acknowledge that a representative of All Dermis Dermatology, PCbilling department is available to explain the charges to me and I agree with this amount.

If, after my insurance pays on my claims and a patient balance becomes due to All Dermis Dermatology, PC, I authorize this office to generate charges to my major credit card account for that unpaid balance without further permission or notice.

Portal Account - A portal account is required to securly send and receive messages from staff as well as to receive copies of receipts/test results/patient summaries.

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        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.

        Click HERE to view the HIPAA form.

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