Welcome to Booth Dermatology and Cosmetic Center! Thank you for choosing us for your dermatological needs. Please note, if a patient is under 18 years of age, a parent or guardian must complete paperwork and attend the appointment with the minor. We are required to update your paperwork EVERY YEAR, by law, regardless of whether anything has changed. We appreciate your cooperation with this matter. Please read over these forms carefully and take your time filling them out fully and legibly.
For patients over the age of 65:
Medications: (Please list all current medications)
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I give permission for you to share my medical information, including but not limited to appointment times & pathology reports with the following people:
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If you wish to hear about services other than what we’ve already provided for you, please let us know! Check all that apply & we’d love to speak with you about them!
Other than the other service we have already provided for you, what additional services would you like to learn about? Please check all that apply!
We make every effort to submit your claims to your insurance company in a timely manner. However, if your statement is returned to our office due to an incorrect address, we will make only one further attempt to contact you via the phone number you’ve provided us.
Consent to Treat: I request and give consent to Booth Dermatology Group, PC (“Booth Dermatology”), its agents, employees, physicians, associates, who may attend to me to provide and perform such medical/surgical care, tests, procedures, liquid nitrogen application, biopsies, injection of medications and local anesthesia, pathology specimen collection, and other services and supplies as are considered necessary or beneficial by my practitioner for my health and well-being. I understand that risks may include pain or stinging during treatment, blistering, scabbing, temporary or permanent skin discoloration, infection, scarring, incomplete removal, the need for repeat treatment, allergic reaction, bleeding, dizziness, or prolonged numbness. I acknowledge that no representations, warranties, or guarantees as to the results or cures have been made to me.
Appointment Adjustments: Booth Dermatology strives to provide the highest level of patient care, and our physicians and staff give patients their undivided attention. Please let us know as soon as possible if you need to adjust or cancel your appointment. An appointment adjustment fee will be charged to any patient who fails to notify us to cancel or reschedule their appointment at least 24 hours in advance of their appointment time. You must notify an office individual, please do not notify the office via voicemail. An office visit appointment adjustment fee is $49. A surgical or cosmetic procedure appointment adjustment fee is $125. This non-refundable fee, which is not covered by insurance, will automatically be charged to the credit card on file and will not be applied to future services. By making an appointment with Booth Dermatology, you agree to these policies and authorize Booth Dermatology to charge your card on file for appointment adjustment fees.
Credit Card on File: At Booth Dermatology, we maintain a credit card on file policy for all patients to streamline the billing process and minimize administrative tasks. It allows us to quickly handle balances from copays, deductibles, and services not covered by insurance, without disrupting your care. The credit card on file must be in the name of the patient or the patient's authorized representative, and must be a credit card (debit cards or FSA/HSA cards will not be accepted as a credit card on file). Credit card information will be kept securely in accordance with all applicable regulations, just as your medical information is.
Should you have a balance after your visit, a statement will be sent. If that statement is not paid, a $35 late fee is assessed and a second statement is issued. After two statements are sent, any remaining balance after 14 days will be charged to your card on file to avoid sending your account to collections. Valid credit card charges which are disputed by the cardholder will incur a $75 administrative fee for our cost and time in response.
Release of Medical Information: I hereby give my consent to Booth Dermatology and/or the physician/practitioner's employees and agents by Booth Dermatology, to provide requested information from my medical record to third party payers and/or other healthcare providers and agents as deemed necessary.
Medicare Patients: I certify that the information given by me in applying for payment under the Social Security Act is correct. I authorize Booth Dermatology to release information from my medical record to the Social Security Administration and/or Medicare program or its intermediaries or carriers or the Professional Standards Review Organization for processing of claims for medical benefits. I request that the payment of authorized benefits be made on my behalf to Booth Dermatology.
Pre-certification: Your insurance company may require a pre-certification, prior authorization, or referral for services such as but not limited to surgery, prescriptions, or services provided at places other than in our facility. It is the patient's responsibility to ensure these have been obtained prior to services being rendered.
Financial Agreement: All payments, deductibles, co-pays, and non-covered services are due at the time of service. We accept cash, personal checks, credit cards, and CareCredit. Self-pay patients, (those not covered by ANY insurance policy or third-party payer) are required to pay for services PRIOR to being seen by the practitioner. The undersigned guarantees payment of the account in full, and agrees to pay the account if a private or governmental insurance carrier does not pay such account. It is the patient’s responsibility to make sure insurance payments are processed and paid promptly to Booth Dermatology; as well as understanding what services are covered under their medical insurance policy. If the amounts due to Booth Dermatology for services rendered become delinquent & the debt is referred to an attorney and/or third party for collections, it is understood and agreed that Booth Dermatology shall recover all costs and expenses incurred in the collection of any such delinquent amount. This includes legal interest on the balance due, together with any collection costs & reasonable attorney fees.
We make every effort to submit your claims to your insurance company in a timely manner. However, if your statement is returned to our office due to an incorrect address, we will make only one further attempt to contact you via the phone number you've provided us.
Worker's Compensation: If you are being seen due to work related injury or illness, we will need appropriate documentation from your employer to file a worker's compensation claim. Without this information the claim will be your responsibility.
Returns/ Refunds: If you purchase a package of treatments from our office, and decide at a later date that you no longer wish to use these services, you may transfer the amount paid towards another service at Booth Dermatology’s discretion. If a single service from your package has already been redeemed, the full price amount of that single service will be deducted from the amount that is being transferred. A product may be returned to our office if it has been unopened, within 30 days of purchasing the product.
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