Contact Information
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Insurance Information
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.
Social History: (Please circle all that apply)
With my consent, Scott Sanders MD, PLLC may use and disclose protected health information (PHI) about me.to carry out treatment, payment, and healthcare operations (TPO). For a more complete description of these uses and disclosures, please refer to the trifold brochure available at the reception desk (Scott Sanders Dermatology, NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES). As a patient, you have the right to review this NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES prior to signing this consent. Scott Sanders MD, PLLC reserves the right to revise its NOTICE OF HEALTH INFORMATION PRIVACY .PRACTICES at any time. A revised NOTICE OF HEALTH INFORMATION PRIVACY PRACTICES may be obtained by forwarding a written request to Scott Sanders MD, PLLC Privacy Officer at 301 North Main Street, -New City, New York 10956.
I further authorize Scott Sanders MD, PLLC and/or his representatives to release results of my medical exams in one or more of the following ways:
With my consent, Scott Sanders MD, PLLC may send by e-mail to my home or other designated location any items that assist the practice in carrying out treatment, payment, and healthcare operations. This includes but is not limited to appointment reminders and patient statements, as long as they are marked “Personal and Confidential.
I have the right to request that Scott Sanders MD, PLLC restrict how it uses or discloses my protected health information to carry out treatment, payment, and health care operations. The practice is not required to agree to my requested restrictions. However, if the practice does agree to those restrictions, it Is then bound by this agreement.
By signing this form, | am consenting to Scott Sanders MD PLLC use and disclosure of my protected health information to carry out treatment, payment, and healthcare operations.| may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. | am aware that if | do not sign this consent, Scott Sanders MD, PLLC may decline to provide treatment to me.
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.
From prior experience we have come to realize the necessity of this statement in order to anticipate some of your questions and concerns and to outline our billing policy. All patients have the opportunity to obtain a copy of this form upon request.
I HAVE READ THE INSURANCE OFFICE POLICY STATED ABOVE AND UNDERSTAND THAT ANY AMOUNT NOT COVERED BY INSURANCE IS MY RESPONSIBILITY.
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.
I hereby authorize all medical and/or surgical benefits to Scott Sanders MD PLLC. This includes all major medical benefits, Medicare /Medigap, HMO and Government sponsored programs, or any other third-party payor for services rendered to me. I understand that I am responsible for all applicable DEDUCTIBLES, COPAYMENTS, COINSURANCE AND NON-COVERED SERVICES as required by my insurance policy.
I hereby authorize Scott Sanders M.D. PLLC to release all information necessary, including medical
records to secure the payment of insurance benefits.
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 ONLY
By signing below, I provide authorization for Medicare to assign benefits to my physician, Scott Sanders MD PLLC.
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.
The information will be used to evaluate any role that the medications that I am taking may play in my skin and overall health, as well as any possible interactions with medications that maybe prescribed to me by Sanders Dermatology.
The information obtained will be kept completely confidential in accordance with current ©HIPPA laws and is intended to help my provider maintain the most up-to-date information and provide the safest and most comprehensive care.
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.