Phoenixville Dermatology Associates

PRIMARY CARE PHYSICIAN

PHONE MESSAGE CONSENT FORM
Notice of Privacy- Patient Acknowledgement

From time to time it may be necessary or desirable to contact patients by phone. To expedite your health care and in the interest of convenience, if you are not available to speak to us directly, we would like to leave a message whenever possible. To assist us in protecting your privacy, please complete the following

Please list the best phone numbers for us to contact you

By signing below, I acknowledge that I have been provided the Notice of Privacy Practices, which contains a detailed description of the uses and disclosures of my health information, and I was given an opportunity to read the notice. I understand I may revoke this consent at any time.

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.

FINANCIAL POLICY

We at Phoenixville Valley Forge Dermatology Associates, PC are committed to providing you with quality care, and we are pleased to discuss our professional fees with you at any time. Please ask if you have any questions about this financial policy.

You agree to allow Phoenixville Valley Forge Dermatology Associates the right to service your account or collect monies you may owe. Our agents may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We also may contact you for marketing purposes via email if you provided us with an email address. Methods of contact may include using pre­ recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

COLLECTION POLICY AND AGENGY FEES

After services have been rendered and your insurance carrier has processed your claim, if there are any balances due you will have the option to pay in full or set up a payment plan. If arrangements have not been made to pay your outstanding balance after the third mailed statement, we will submit your account to our collection agency.

Agreement To Pay: If my account were to go to collections, I, the undersigned accept the fee charged (25% of the balance due) as a legal and lawful debt and agree to pay said fee.

I / We have read this disclosure and policies and agree with the above.

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.

CANCELLATIONS/ NO SHOWS FOR ALL MEDICAL AND SURGICAL APPOINTMENTS

We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family.

We ask that if possible you call to cancel at least 24 hours in advance of your scheduled appointment.

There will be no charge for cancellations.

No shows will result in a twenty-five-dollar ($25.00} charge; this will not be covered by your insurance.

Payment of this fee will be required prior to your next office visit.

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. Filling out and submitting this paperwork is NOT scheduling an appointment - Please call the office to schedule your appointment.