Payment is required for all services at the time they are rendered. If your visit is provided under contracted insurance coverage, all co-payments, co-insurance, and deductibles are due at the time of service. Any account balances are delinquent after 30 days. Delinquent accounts will incur a monthly billing fee of $10 or 1.5%, whichever is greater. In addition to understanding the billing policy, I assign all insurance benefits and additional payer benefits to Carson Dermatology for services provided by them. I authorize release of medical information as necessary for insurance claims, applications, and prescriptions, and I authorize release to my primary care physician, referring physicians, as well as consultants, as needed.
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.
In 1996, Congress passed a series of legislative acts designed to assure the security and confidentiality of medical records and information. This legislation is collectively known as HIPAA. All medical facilities and providers are required to comply with these requirements as of April 14, 2003.
Permitted uses and disclosures of your medical information:
You are entitled to:
We are additionally required to:
acknowledge I have been given this form, offered a copy of the privacy policy, and had the opportunity to ask any questions.
The patient declined to sign and /or review or acknowledge this form.
HIPAA regulations require we keep your health information confidential. You do have the right to grant access to this information to family, significant other, or any other person; please complete this authorization.
Please list those individuals to whom you authorize the release of your health information. (ie: medical condition, diagnosis, test results, appointments, and other pertinent health reports.)
Name:
Your information will be encrypted.
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