Demographics Form - English

Dermatology Sonoma & Santa Rosa

Please correct the errors described below.

INSURANCE INFORMATION

Emergency Contact Information

PLEASE NOTE OUR BILLING POLICY AND INDICATE YOUR ACCEPTANCE BY SIGNING BELOW:

IF YOUR CHECK IS NOT HONORED BY YOUR BANK YOU WILL BE CHARGED $30 FEE BY THE OFFICE. IF YOU CAN NOT KEEP YOUR SCHEDULED APPOINTMENT, WE REQUEST 24 HOUR CANCELLATION NOTICE. WE RESERVE THE RIGHT TO CHARGE A $50 FEE FOR MISSED OFFICE VISITS AND $100 FEE FOR MISSED SURGICAL OR COSMETIC VISITS. YOU ARE RESPONSIBLE FOR CHARGES APPLIED TO YOUR DEDUCTIBLE, COINSURANCE, COPAY AND ANY NON-COVERED SERVICES. YOUR COPAY IS DUE ON DATE OF SERVICE. THE PATIENT IS ULTIMATELY RESPONSIBLE FOR PAYMENT OF BALANCES NOT COVERED BY INSURANCE. YOU AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO SANTA ROSA OR SONOMA DERMATOLOGY.

PATIENT OR RESPONSIBLE PARTY

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.

FINANCIAL POLICY: : Payment for service is due in full at the time service is provided. For patients with insurance: copayments and deductibles are due at the time of service. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than you anticipated for care. Any care not paid for by your insurance carrier will be the patient’s responsibility.

If you are having financial problems or have a question about your bill, please call the office. We are always happy to review your charges to be sure they are correct and fair. We will work with you to agree on a reasonable payment schedule, if necessary. We know that you want to keep your account in good standing. If no specific arrangements are made, any account 120 days or older will be referred to an outside collection agency


ASSIGNMENT OF INSURANCE BENEFITS: Please read and initial below:

PRIVACY POLICY: I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information, I understand that this information can and will be used to:

  • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I may request your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY STATEMENT AND PRIVACY POLICY. I UNDERSTAND THAT I AM ULTIMATELY RESPONSIBLE FOR ALL CHARGES REGARDLESS OF WHETHER OR NOT COVERED BY INSURANCE. I HEREBY AUTHORIZE RELEASE OF ALL INFORMATION NECESSARY TO SECURE PAYMENT.

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.

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