Welcome to Hecker Dermatology Group, P.A.

Please take a moment to become familiar with our office policies and procedures.

• If your Insurance company requires a referral or co-payment, please give it to the front desk personnel upon check-in.
• Referrals are the responsibility of the patient to obtain.
• Co-pays must be paid at each visit prior to seeing the provider.
• You must present your insurance(s) and photo ID at each visit.
• A medical records release form must be completed before any records are duplicated. A clerical fee of $1.00 per page will be charged to the patient for a copy of the medical record.
• If you were told that your primary care office would fax a referral, you must call our office 24 hours prior to your appointment to verify that we received your referral. If we do not have your referral here at appointment time, you will be asked to reschedule your appointment.

Hecker Dermatology Group, P.A. Missed Appointment Policy

Hecker Dermatology Group, P.A. attempts to be as flexible as possible regarding emergencies
and forgetfulness when it comes to missed appointments. However, it is not our responsibility
to make sure a patient keeps their appointments, but we do our best to ensure that they are
reminded. We make every attempt to call patients 1-2 days prior to their appointment as a
reminder.

• If a confirmed regular appointment is missed without 24-hour notice of cancellation, a charge of $25.00 will be billed to the patient’s account.
• A $50.00 charge will be billed to a patient’s account for a missed surgical appointment.
• Patients cannot make future appointments unless their missed appointment fee is paid.
• Upon multiple no-shows, the patient is requested to seek Dermatologic care elsewhere.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.