Patient Information Form

Please correct the errors described below.

THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS:

MAILING ADDRESS:

PARENT, SPOUSE, OR RESPONSIBLE PARTY (if different from patient)

INSURANCE COVERAGE

EMERGENCY CONTACT INFORMATION:

If yes, please provide their names and phone numbers below.

DERMATOLOGY MEDICAL HISTORY

Women

RECEIPT OF NOTICE OF PRIVACY PRACTICES:

The Health Insurance Portability and Accountability Act (HIPAA):

Your rights to your health information:

  • Get an electronic or paper copy of your medical record
  • Ask us to correct your medical record
  • Request confidential communications
  • Ask us to limit what we use or share
  • Get a list of those with whom we've shared information
  • Get a copy of our privacy notice
  • Choose someone to act for you
  • File a complaint in you feel your rights are violated

For certain health information, you can tell us your choices about what we share:

  • You have the right and choice to tell us what family members or friends you would like information shared
  • We will never share your information for marketing purposes without your written consent
  • We will never sell your personal information

We typically will use or share your health information in the following ways:

  • With professionals who are treating you
  • To run our practice, improve your care, and contact you when necessary
  • To bill and get payment from health plans and other entities
  • To help with public health and safety issues
  • To do research
  • To comply with the law
  • To respond to organ and tissue donation requests
  • To work with a medical examiner or funeral director
  • To Address workers' compensation, law enforcement and other government requests
  • To respond to lawsuits and legal actions

Our responsibilities:

  • We are required by law to maintain the privacy and security of your protected health information
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described her unless you tell us we can in writing.

This is a summary of our Notice of Privacy Practices. If you would like a full copy please notify the front desk.

My signature indicates that I have been given the opportunity to received or review a copy of my physician's Notice of Privacy Practices and understand my rights on how medical information may be used and disclosed, and how I can access my health 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.

Patient Financial Responsibility Consent Form

Please read the following carefully regarding patient responsibility for payment of your care and services.

Insurance Claims: Providers at Durango Dermatology participate with most insurance companies, but not all plans under all companies are accepted. In order to avoid unexpected charges, it is the patient’s responsibility to confirm that your particular health benefit plan is contracted with Durango Dermatology. Although we will do our best to guide patients through this process, it is impossible for our front desk to keep abreast of the requirements of the thousands of insurance products that are on the market today. Ultimately it is the patient’s individual responsibility to understand the provisions, limits, and requirements of their individual benefit plan and advise us accordingly. Patients will be responsible for insuring payment for all medical services provided. If a carrier denies payment for services because a plan requirement wasn’t met, services were considered “non-covered”, the plan benefits were exceeded, or treatment was considered medically unnecessary or experimental, patients will be responsible for those charges. Please bring your insurance card to each visit in case there are any changes with your coverage. If there are any financial problems, we will absolutely work with you on a reasonable payment plan so that it is not a deterrent to you obtaining medical care.

Referrals and Authorizations: As a specialist, some insurance companies (particularly HMOs, VA and Tricare) require that prior to any visit you must obtain an authorization or referral from your primary care physician. It is your responsibility to know if this is required by your insurance, and if so, to obtain the referral. If your insurance company rejects a claim because a valid authorization or referral was not in place, the full cost of the visit will be your responsibility.

Patients Without Insurance: As a courtesy for our patients, Durango Dermatology has created a self- pay fee schedule which includes a discount from our normal fees. Payment is expected at time of service. If a patient cannot pay in full, please contact our office manager to work out an acceptable payment plan.

Labwork: There may be times that Durango Dermatology will need to seek outside consults for labwork or pathology. We will do our best to keep you informed when this may happen, but the patient will be responsible for these outside charges.

No Show Fee: We understand things will come up which may require canceling an appointment. Please call us as soon as possible to let us know if you will have to miss an appointment so that we may fill the appointment slot. If a patient misses an appointment and does not call to let us know, you will be charged a $25 no show fee that will be donated to Camp Discovery which offers children living with a chronic skin condition a one-of-a-kind camp experience. We, unfortunately, needed to incorporate this fee due to a high no show rate combined with a long waitlist for appointments.

Billing Questions: Durango Dermatology has contracted with Dermatology RCM for our billing and collection services. Billing questions should be directed to their office at (407) 335-4900.

I understand the above regarding patient responsibility at the time of service and I do not have any questions at this time regarding payment for the medical services provided.

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.

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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.

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