New Patient Packet

Please correct the errors described below.

Dear Patient,

Welcome to Fuchs Dermatology. Thank you for filling out this paperwork ahead of time. This makes the check-in process easier for all of us, and we appreciate it. All forms must be completed in their entirety. Please note that the last form is to keep your credit card in our HIPAA encrypted certified system. Please remember to bring your Insurance card(s), a picture Identification, and the credit card you’ve included in this paperwork

All necessary precautions are being taken to provide the best and safest care to each and every patient. HEPA filters have been installed in all patient areas, plexiglass barriers have been mounted at the check-in counters, and increased sanitation occurs between all patient encounters. Our goal is to provide you with top quality care in a safe environment. In that regard, if you are over the age of 18 or do not require assistance, please come to your appointment alone. We schedule appointments in a manner to accommodate social distancing. This also applies to arriving on time to your appointment. Plan on walking in the door right at your appointment time. If you arrive late, you may be asked to reschedule.

Our Virginia Office is located at 611 South Carlin Springs Road, Suite 502, Arlington, Virginia 22204. We are located ½ mile South of Route 50 and ½ mile North of Columbia Pike. Our office shares a driveway with Long Branch Nature Center and sits between the Campbell Elementary School and the old Urgent Care Building, so look for those Landmarks when looking for the turn. The parking garage fee is currently $5.00. If you would like to pay by cash you will have to pay through a kiosk on the lobby level (1st floor). To pay the parking by credit card, you may pay at the lobby kiosk or at the exit gate. Handicapped Parking is available in the front of the building, free of charge, as space allows.

Our DC Office is located at 2021 K Street, Suite 508, Washington, DC 20006. We are located at 20th and K Streets. The closest metro stops are at Farragut West and Foggy Bottom. There is a parking garage at the building, however, the fees are typical for DC parking garages. There may be street parking, but it is advised to look closely for signage. Do not park where you are not allowed.

Thank you,
Fuchs’ Staff

Patient Registration

THIS OFFICE WILL SUBMIT TO THE FOLLOWING HEALTH INSURANCE CARRIERS: MEDICARE, CAREFIRST BLUE CROSS/BLUE SHIELD, ANTHEM BLUE SHIELD OF VA, AETNA, AND TRICARE. WE DO NOT TAKE MEDICAID. IF YOU HAVE ANY OTHER INSURANCE CARRIER, YOU WILL BE EXPECTED TO PAY AT THE TIME OF YOUR VISIT AND SEEK REIMBURSEMENT FOR SERVICES RENDERED. PAYMENT IS EXPECTED AT THE TIME OF SERVICE FOR ALL COSMETIC SERVICES. IF YOU ARE NOT PREPARED TO PAY AT THE TIME OF SERVICE, PLEASE RESCHEDULE YOUR COSMETIC VISIT. THANK YOU.

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PATIENT AUTHORIZATION

I HEREBY AUTHORIZE GLENN H FUCHS, MD, PC TO APPLY FOR BENEFITS ON MY BEHALF FOR COVERED SERVICES RENDERED. I REQUEST PAYMENT FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO THE ABOVE-NAMED PHYSICIAN.

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.

New Patient History

Skin History

Family History

Smoking History

Review of Systems

Alerts

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.

Acknowledgement of Receipt of Notice of Privacy Practices

Our NOTICE OF PRIVACY PRACTICES provides information about how we may use and disclose protected health information about you. The NOTICE contains a Patient Rights section describing your right under the law. You have the right to review our NOTICE before SIGNING this consent. The terms of our NOTICE may change. If we change our notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information for you is used or disclosed for treatment, payment, and healthcare operations.

By signing this form, you consent, to our use and disclosure of protected health information about you for treatment, payment, and healthcare operations. You have the right to revoke this consent, IN WRITING, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

  • PROTECTED HEALTHCARE INFORMATION MAY BE DISCLOSED OR USED FOR TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS.
  • THE PRACTICE HAS A NOTICE OF PRIVACY PRACTICES AND THAT THE PATIENT HAS THE OPPORTUNITY TO REVIEW THIS NOTICE AND RECEIVE A COPY IF REQUESTED BY THE PATIENT OR THEIR REPRESENTATIVE.
  • THE PATIENT RESERVES THE RIGHT TO CHANGE THE NOTICE OF PRIVACY POLICIES.
  • THE PATIENT HAS THE RIGHT TO RESTRICT THE USES OF THEIR INFORMATION BUT THE DISCLOSURES WILL THEN CEASE.
  • THE PRACTICE MAY CONDITION TREATMENT UPON THE EXECUTION OF THIS CONSENT.
  • THIS OFFICE MAY LEAVE A VOICE MESSAGE REGARDING SCHEDULED APPOINTMENTS ON ANSWERING SYSTEMS.
  • I HAVE SEEN THIS OFFICE’S NOTICE OF PRIVACY PRACTICES AND CONSENT TO ITS POLICIES.

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.

Credit Card Agreement

Please fill out information below for any other person(s) you authorize this credit card for

Add Additional Names

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.

Frequently Asked Questions

Regarding the Credit Card on File Agreement Do I have to leave my credit card information to be a patient at this practice? Yes. This is our policy and it is a growing trend in the healthcare industry. Insurance reimbursements are declining and there has been a large increase in patient deductibles. These factors are driving offices to either squeeze more patients into shorter periods of time or to stop accepting insurance. We have decided to focus on becoming more efficient in our billing and collections processes instead.

How much and when will money be taken from my account? The insurance companies on average take approximately 2 weeks to process submitted claims. Whatever the allowed amount is, your copay, coinsurance, and deductible are taken into consideration. It simply depends on your individual policy what you may owe. Once the insurance explanation of benefits is received and posted to your account.

How do you safeguard the credit information you keep on file? We use the same methods to guard your credit card information as we do for your medical information. The card information is securely protected by the credit card processing component of our HIPAA compliant practice management system. This system stores the card information for future transactions using the same sort of technology that any online retailer would. We can’t see the card number – only the last four numbers, giving us no way to use the card outside of the billing system. There is no way to export the card information out of our system. The only way to use it is to process a payment in our practice management system.

What are the benefits? It saves you time and eliminates the need to write checks, buy stamps or worry about delays in the mail. It also drives our administrative costs down because our staff sends out fewer statements and spends less time taking credit card information over the phone or entering it from the billing slips sent in the mail, which are less secure methods than us storing the information. The extra time the staff has can now be spent on directly helping the patients, either over the phone, with insurance claims or in person. I always pay my bills on time.

Why do I have to do this? The entire billing process is time consuming and wasteful, and the few patients that we do have to send to a collection agency end up costing a lot of money. Reducing unnecessary costs are essential to allowing us to continue to be an in-network provider with many insurance companies. Nothing is changing about how much you end up paying

What if there is a payment discrepancy or I have other payment questions? Please contact our billing department directly to settle payment discrepancies or for other payment questions. This policy in no way compromises your ability to dispute a charge or questions your insurance company’s explanation of benefits

May I request a statement of services by mail? Yes.

Financial Policy and Payment Arrangements

Welcome to our Practice! We’re happy to have you as a patient. Before your visit, we would appreciate you reading and signing this form regarding our financial policies.

Thank you!

If your insurance is one that we accept and submit to, then we would like you to sign stating that you understand you will be responsible for any amount that your insurance approves but does not pay either by deductible or copay. To reduce hand-to-hand exposure, our policy is to keep your credit card on file. It is triple encrypted and secure.

COSMETIC PROCEDURE/PRODUCTS ARE NOT COVERED BY INSURANCE. BALANCES FOR THESE SERVICES ARE EXPECTED AT THE TIME OF SERVICE. PLEASE SCHEDULE YOUR ELECTIVE PROCEDURE ACCORDINGLY. If you have a copay for your office visits, you will be required to pay for that at the time of each 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.

Your information will be encrypted.

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