Patient Contact Information

Dear Patient:

Thank you for being a valued patient of our dermatology practice! Wegman Dermatology, PLLC is part of your PatientCentered Medical Home Neighborhood. We look forward to providing you with quality dermatologic care in a warm and friendly environment. Your healthcare is our primary concern, and we partner with your Primary Care Physician to efficiently co-manage your healthcare over time. As your dermatology provider, we will be sharing limited or long-term management (depending on the nature and impact) of your condition and will provide you with advice, guidance, and periodic follow up for as long as you need. Our philosophy is to provide comprehensive care while treating every patient with dignity and respect. Examining the skin can be an involved process and delays may occur as our providers are very thorough. Please see the information under each of the headings listed below. We understand that coming in for a medical appointment can, often, cause apprehension and concern and we want you to feel comfortable when you arrive for your appointment Wegman Dermatology. This information can answer many questions about how our practice operates.

WHAT TO EXPECT AT YOUR APPOINTMENT

When you arrive at your appointment, you will be asked for your insurance cards, driver’s license, and a list of medications. On the day of your appointment at check in, you will be asked to pay your copay, deductible (if not met), and coinsurance (if applicable). This payment policy does NOT apply to those patients with government issued Medicare and all Medicaid patients. In addition to the enclosed forms, you will also be asked to fill out a questionnaire related to your visit with Wegman Dermatology on the day of your appointment.

Enclosed are the intake forms that you need to fill out completely before your appointment with Wegman Dermatology. Regarding forms requiring a witness for patient signatures, please sign these forms when completing the packet BEFORE your appointment. The signatures will be witnessed by our staff at the time of your appointment. Please return these completed forms to the office on or before your appointment with Wegman Dermatology. All forms will be reviewed with you on an annual basis. According to practice and governmental regulations, you will be asked to fill these forms out at regular intervals. Please keep in mind that if the forms are NOT completely filled out, you may experience greater wait times once you are in the office for your appointment.

Our clinicians aim to provide quality medical care to each of our patients and this involves taking a detailed history and completing a comprehensive physical examination of each patient. New patients and returning patients who are scheduled for an annual exam will have their skin evaluated from head to toe. To provide the best quality care, your skin should be in its natural form for your appointment. Patients are expected to have clean hair, skin, and nails. In addition, patients must remove all cosmetics (makeup, etc…) from their skin and their nails should be clear (without nail polish). This process is lengthy and, therefore, patient appointments with our practice usually take approximately 2 hours.

ATTENTION NEW PATIENTS

We strive to make your first appointment here successful and enjoyable for you and our staff! To make this happen, we ask that all new patients arrive 30 minutes prior to your new patient appointment so we can perform our intake process and make sure we have everything in place for the provider. We also ask that you return your new patient forms (included in this packet) BEFORE the day of the appointment if possible. Or you can fill the patient forms out online and send them securely to our office via a secure email. Also, if you are being seen for a specific area on your skin, we ask that you send us a picture {to our practice cell phone at 989-277-5240} of the area that you are concerned about so our clinicians can properly triage your condition and prepare for your visit.

OFFICE HOURS, SCHEDULING, & CONFIRMATION OF APPOINTMENTS

Patients are scheduled Monday through Friday. Our telephones are answered from 10 AM until 4 PM on Mondays -Fridays except during the lunch hour (11:30 AM-1:30 PM). If we are not able to answer your call, you may leave a message on our voicemail and your call will be returned promptly. We will attempt to confirm your appointment using multiple modes of communication (email, phone, and text messaging). The process to confirm an appointment begins a few days to a week before your scheduled appointment. Please acknowledge your appointment during one of our confirmation contacts. We will continue calling to confirm your appointment until we hear from you. We also send “just in time” text reminders the day of your appointment. Patients who are unresponsive or no-show their appointment may be charged a missed appointment fee.

INSURANCE & PAYMENT INFORMATION

We will try to verify your insurance coverage, including your deductible and copays prior to your appointment. Please call the office if your insurance has changed since your last appointment. For payments, the practice accepts credit cards (VISA, MASTERCARD, AMERICAN EXPRESS, and DISCOVER), cash, money orders, Venmo (@WegmanDermatology), and personal checks (written to Wegman Dermatology, PLLC). We also offer a credit card option through CareCredit, which offers a no interest plan if paid within the time frame selected. Patients with HMO insurance are required to obtain authorization from their Primary Care Physician so they can be seen by Wegman Dermatology. It is the patient’s responsibility to obtain this authorization from their Primary Care Physician (Doctor/ NP/ PA) and patients who arrive to their appointment without a proper HMO authorization will be asked to pay out of pocket for the visit or will be asked to reschedule their appointment.

COORDINATION OF CARE & PATIENT PORTAL

You may notice that we will be communicating with your Primary Care Physician and may be providing them with timely written reports on our consultations with you, including all diagnostic testing results and medications that we order for you. In addition, we may notify your Primary Care Physician of cancellations, missed appointments, and other actions that may place your care in jeopardy. If your care requires a referral to another physician, we will inform your Primary Care Physician of any additional referral(s) that our practice recommend(s).

Wegman Dermatology provides each patient with access to their electronic health record via our patient portal. This is a unique feature that allows patients the ability to request change of information, request medication refills, request appointments, send messages to the office, and review documents in their electronic medical record such as diagnostic testing results and visit notes. If you would like to use your patient portal, please provide your email address on the enclosed forms and our intake questionnaire. Our staff will be happy to help you establish your patient portal.

AFTER HOURS/EXTENDED ACCESS POLICY

Wegman Dermatology, PLLC offers its patients after-hours medical care if they are having a medical concern after our business hours (8 AM- 5 PM, Monday-Thursday). Patients are directed to call our office’s after-hours phone numbers: 989-725-2702 OR 989-277-5240 (Monday-Thursday from 5:00 PM to 8 AM and on Fridays, Saturdays, and Sundays) if they feel that they need to contact the practice after hours for a medical question or concern. If Dr. Wegman and/or Meghan Muladore, DNP are out of the area and/or unavailable to come into the office, patients may be directed to an area urgent care facility. As always, if a patient feels that they are experiencing a medical emergency, they should call 911 or go directly to their nearest Emergency Department.

PATIENT RESPONSIBILITIES

We trust you, our patient to:

• Keep your appointments as scheduled or call to let us know when you cannot keep an appointment.
• Learn about your insurance so you know what it covers.
• Follow the care plan that is agreed upon or let us know why you cannot so that we can try to help or change the plan.
• Tell us what medications you are taking and ask for refills at your next scheduled appointment.
• Tell us about emergency care or hospitalization(s) you receive. refills at your next scheduled appointment.
• Tell us about emergency care or hospitalization(s) you receive.

In addition…

• Be mindful of the energy that you bring to our practice…
• Your words and actions have meaning.
• We will respect each one of our patients while providing the best possible care.
• We also expect you, in turn, to be respectful of our staff.

If you have any questions for the office staff, please do not hesitate to call the office before your appointment. We look forward to seeing you at your next appointment with Wegman Dermatology, PLLC!

Sincerely,

Wegman Dermatology Staff

PATIENT CONTACT INFORMATION

If the patient is under the age of 18 OR has a legal guardian, the patient’s parent and/or legal guardian must be present at all appointments.

DESIGNATED REPRESENTATIVE(S) INFORMATION

Our office staff may discuss your test results or other medical information regarding your care with the person(s) listed below:

**Please note that we will not leave any medical information on an answering machine**

(Your information may not be discussed with your spouse, parent, or any other person unless listed in this section of the form.)

EMERGENCY CONTACT INFORMATION

Please provide the name(s) of person(s) **NOT** living in your home. This person would ONLY be contacted if we were UNABLE to reach you at your phone number(s) and/or address provided. We will NOT provide medical information to these people.

Skin Conditions

PAST SURGICAL HISTORY

FAMILY MEDICAL HISTORY

PERSONAL MEDICAL HISTORY

SOCIAL HISTORY

YOUR FINANCIAL RESPONSIBILITIES

I understand that as a courtesy to me, Wegman Dermatology, PLLC may bill my claim to my insurance company according to the rules or policies of my insurance company. I authorize my insurance company to send their determination and/or payment of my insurance claim directly to Wegman Dermatology, PLLC. I understand that Wegman Dermatology, PLLC participates with most Blue Cross policies, Medicare, several HMO’s and other commercial insurance companies. If my insurance company requires a referral from my primary physician to process my claim, I understand that it is my responsibility to obtain the referral. If I do not obtain a referral, I agree to be responsible for payment of the claim. If I have insurance with which Wegman Dermatology, PLLC does not contract, or I do not have insurance, or a medical service performed is not covered by my insurance plan, my signature on this form indicates my acceptance of my all financial responsibility for all charges incurred at my visit. I authorize Wegman Dermatology, PLLC to release any personal, medical, and/or financial information (including alcohol, drug abuse, mental health, HIV, AIDS & AIDS related complex treatment) related to my care, to my insurance carrier(s) or persons/agency responsible for the processing of my medical claim.

I understand that for my best medical care the clinicians at Wegman Dermatology, PLLC prefer to do a complete skin evaluation. During my evaluations, our providers may diagnose skin conditions that they consider to be medically necessary or advisable to treat today. The treatment of these conditions will be billed separately from the office call to my insurance company according to general coding guidelines. Diagnosis of some conditions may require a KOH, which is a scraping of the skin that will examine under the microscope. Certain wounds require treatment with special surgical dressings and/or debridement that will also be billed separately to my insurance company. Cryotherapy is the application of Liquid Nitrogen, which is an extremely cold substance used to freeze/burn lesions or growths on the skin. Your insurance company may call this procedure a “surgery” on your explanation of benefits. If an area treated today does not resolve, your insurance will be charged for whatever treatment is necessary when you return. Some conditions require more than one treatment. Each time you are treated with Liquid Nitrogen, your insurance company will be billed. Any of these above medically necessary procedures that are performed today will be billed to my insurance in accordance with coding guidelines and insurance regulations.

I understand that I will receive a statement from Wegman Dermatology, PLLC’s office if a balance remains after my insurance company processes my claim and determines that I am responsible for a co-pay, co-insurance, deductible or any other amount that my insurance company approves but does not pay to Wegman Dermatology, PLLC. This unpaid balance will remain my responsibility until it is paid. I agree to be responsible for any balance my insurance company determines I am responsible for and does not pay to Wegman Dermatology, PLLC. Wegman Dermatology, PLLC offers several methods of paying my balance due. I may mail my payment, bring it to the office, or call and have the balance or a partial payment applied to my credit card. If the check I use to make payment from my bank account has insufficient funds, I will be charged any bank fees that Wegman Dermatology, PLLC incurs because of the transaction. When possible, my deductible and copay will be determined prior to my visit. The office may call me to ask that I bring my office call copay and/or approximately $150 of my deductible to my appointment. These payments will be applied to any charges processed but not paid by my insurance company. If I am experiencing a financial hardship a CareCredit application can be submitted at my appointment. In addition, I may set up a payment plan. If I have any questions regarding my charges or remaining balance, I may ask to speak to the Billing Specialist. I understand that Wegman Dermatology, PLLC charges a no-show fee for any missed appointments. I understand that Wegman Dermatology, PLLC charges a no-show fee for any missed appointments. If I do not show an appointment or cancel within 24 hours, I may be charged a cancellation fee ($ 50) or a missed appointment fee ($75-150, depending on the appointment type). Missed appointment and cancellation fees can be avoided if you give the office at least 24 hours’ notice to cancel an appointment. We understand that emergencies arise sometimes so if you have to cancel your appointment within 24 hours, please call the office and the cancellation/ missed appointment fee may be waived. I have been made aware of and agree to the financial responsibilities and insurance information stated above. I permit a copy of this authorization to be used in place of the original. This authorization is valid until I provide Wegman Dermatology, PLLC with written revocation.

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.

MEDICARE AUTHORIZATION

I request that payment of authorized Medicare benefits be made on my behalf to Wegman Dermatology, PLLC for any services furnished to me by him or his office staff at his direction. I authorize any holder of my personal medical records to release to the Health Care Financing Administration, or its agents, any information needed to determine these benefits or the benefits payable for related services. I permit a copy of this authorization to be used in place of the original. This authorization is valid until I provide Wegman Dermatology, PLLC with written revocation.

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.

GENERAL CONSENT FORM AND PRIVACY PRACTICES

The protection of your identity and the privacy of your personal medical information is very important to our office. To comply with new government rulings we are required to verify your identity at each appointment by asking you for a photo ID and your insurance card. In addition, your identity must be confirmed when you call with questions regarding your condition, prescription refills, requesting or cancelling an appointment, and account demographic changes.

The following information will assist us in your care and in our communications with you, while protecting your confidentiality.

1. RECORDS: Your signature below indicates that you authorize Wegman Dermatology, PLLC to retrieve any data, films, records, slides, medical records, and laboratory or pathology reports from other providers/labs to assist in your treatment.
2. RISK: Your signature below indicates that in the event that Wegman Dermatology, PLLC or any of its employees is exposed to your blood or body fluids, you have been informed that an HIV antibody test may be performed on you. (Public Act 488).
3. CONTACT: : Your signature below indicates that you authorize Wegman Dermatology, PLLC to contact, leave a message on your home answering machine, and/or mail to you, your spouse, or a minor’s parent, at your home address information regarding your medical condition, your account statement, appointment information, or insurance items.
4. PHOTOGRAPHS: YYour condition may need to be photographed by our clinician(s) for educational/scientific/medical record purposes. Your signature also indicates you have been informed that any pictures taken will remain the property of Wegman Dermatology, PLLC. If your pictures are used for education or research, you will NOT be identified by name.
   [Example: a picture of your mole, cancer site, or unusual skin condition.]
5. MEDICATION HISTORY: My signature below gives my permission for Wegman Dermatology, PLLC or his representative to obtain a list of all of my current and previous medications from my pharmacy or from a website that stores all medications my insurance company has processed.

6. PATIENT PORTAL, DIRECT MESSAGING, & REGISTRY REPORTING: Your signature below indicates that you understand that the Affordable Care Act has required that physician’s offices share information with you, your other physicians, and regulatory registries electronically. Please be assured that this is always done in a secure or encrypted method. Some reports to regulatory registries may require statistical information from your encounter but your name will not be included.

7. HIPAA: My signature below indicates that I have received and/or reviewed or have declined to receive and/or review a copy of Wegman Dermatology, PLLC’s Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). My signature allows Wegman Dermatology, PLLC to keep this information in my medical chart. A separate Privacy Practices Acknowledgement Form may be reviewed and signed at my request.

Because of the importance of each of these notifications, if I do not sign this form, Wegman Dermatology, PLLC may need to decline to provide my dermatologic care. This form is valid indefinitely or until I provide written revocation.

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.

****** IT IS OKAY TO SIGN DOCUMENT IT WILL BE WITNESSED BY STAFF ON THE APPT DATE *********

CONSENT FOR TREATMENT

I understand that for my best medical care, our providers at Wegman Dermatology, PLLC prefer to do a complete skin evaluation. During this evaluation, our clinicians may diagnose skin conditions that they consider to be medically necessary or advisable to treat today. The treatment of these conditions will be billed separately from the office call to my insurance company according to general coding guidelines. Diagnosis of some conditions may require a KOH, which is a scraping of the skin that one of our providers will examine under the microscope. Certain wounds require treatment with special surgical dressings and/or debridement that will also be billed separately to my insurance company. Any procedure provided to treat a medically necessary condition will be billed to my insurance.

Conditions that are not medically necessary to treat, such as Seborrheic Keratoses, Milia, Skin Tags, etc., may be noted by our providers during your exam. Depending on the amount of time available in your appointment they may treat these areas at your request and at their discretion. Procedures provided to treat a condition that is not medically necessary will be your personal financial responsibility.

Cryotherapy is the application of Liquid Nitrogen, which is an extremely cold substance used to freeze/burn lesions or growths on the skin. Your insurance company may call this procedure a “surgery” on your explanation of benefits. If an area treated today does not resolve your insurance will be charged for whatever treatment is necessary when you return. Most Warts and some precancerous growths (Actinic Keratoses) require more than one treatment, and the appointment will be scheduled today. When you return to the office to have areas re-treated with liquid nitrogen, your insurance company will be billed again. These are correct billing procedures according to coding guidelines.

By signing below, I indicate that our provider(s) or their representative has discussed the above treatment or procedure with me and has explained the information that is briefly summarized below:

1. The nature, purpose, benefits, and intended outcome of the recommended treatment or procedure.
2. The risks and possible complications of the recommended procedure. I am aware that in addition to the specific risks of the treatment or procedure explained to me, as in any procedure, there are other risks such as infection, scar tissue, poor healing process, minimal blood loss.
3. The prognosis (medical prediction) if the treatment or procedure is refused.

I understand that the practice of medicine and surgery is not an exact science, and that no guarantees have been made concerning the results of any procedure. I feel I have had sufficient opportunity to discuss my condition with our clinician(s) and/or their staff and all my questions have been answered to my satisfaction.

• I believe that I have adequate knowledge and understanding upon which to base an informed consent to the treatment or procedure.
• I understand and authorize that my insurance will be charged for an office call and for any medically necessary diagnostic or treatment procedures performed today.
• I understand that if procedure(s) that are not medically necessary are performed, I am responsible for payment for those services.
• I also understand that I may be responsible for any charges that are approved but not paid by my insurance such as my deductible, copay, and co-insurance.
• My signature is valid for one year from the date signed unless I provide written revocation.

If you have questions regarding the fees for treatment, please ask to speak to our billing department.

***IT IS OKAY TO SIGN DOCUMENT - IT WILL BE WITNESSED BY STAFF ON THE APPT DATE***

MEDICATION & ALLERGY INVENTOY