New Patient Paperwork (Lawlor Dermatology)

MEDICAL HISTORY

Past medical history:

Patient Contact Information

Insurance policy holder information / responsible party complete:

Emergency Contact:

As a patient of our practice, from time to time we may need to communicate with you. To preserve your privacy, please indicate your preferred method for us to communicate medical information to you and others involved in your care.

Examples of medical information include test results, appointment reminders, and other information of a clinical nature.

Without specific permission, we will not release your medical information.

Please identify those individuals to whom we may release your medical information.

I assume responsibility to inform the practice of changes in my telephone numbers and my preferences

Patient HIPAA Consent Form

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to conduct:

• Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

• Obtaining payment from third party payers (e.g. my insurance company);

• The day-to-day health care operations of your practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that your practice maintains the most up to date version of its Notice of Privacy Practices. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoked this consent is not affected.

Patient Financial Responsibility Agreement

Thank you for choosing Lawlor Dermatology for your cosmetic needs. It is our pleasure to offer you the latest cutting edge services and medical grade products to meet your skin care needs. Please take a moment to familiarize yourself with our policies.

Payment:

This account is self-pay and payment is required in full at the time of each service. Various insurance policies are accepted for medical visits. We accept the following forms of payment: Cash, Checks (with valid ID; no out of state), Visa, MasterCard, Discover. Financing options are available through CareCredit and Cherry. There is a returned check charge of $30.

Gift Cards and Packages:

Gift cards are available and may be redeemed for specific cosmetic services and packages. Packages offer our clients significant savings. Services purchased as a package are not transferable. If you are unable to use your full package, a credit may be issued at the discretion of the Provider. Refunds will not be provided. Credits are not transferable. Packages must be redeemed within 1 year of purchase.

Promotions:

Special promotions may not be combined with any other discounts.

Cancellation Policy:

Lawlor Dermatology reserves the right to charge a $25 fee for the following:

• Dermatology appointments canceled 24 hours or less of scheduled appointment

• Dermatology no show appointments

Lawlor Dermatology reserves the right to charge a $150 fee for the following:

• Cosmetic appointments canceled 24 hours or less of scheduled appointment

• Cosmetic no show appointments

Outstanding fees must be paid in full prior to rescheduling a missed appointment.

Arriving late will deprive you of valuable treatment time. We will make every effort to perform your entire treatment in the remaining scheduled time, but reserve the right to reschedule your appointment if you arrive more than 10 minutes late and charge the fee listed above.

I clearly understand and agree that all services rendered to me may be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me or to my dependent up to the point of termination will be immediately due and payable.

I acknowledge that I am responsible for any outstanding fees for services provided to me by Lawlor Dermatology.

Any other arrangements that may involve payment plan or payment deferral must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable.

I acknowledge that Lawlor Dermatology reserves the right to charge 50% of the desired service if I cancel the scheduled appointment 24 hours or less on the day prior to my appointment. I acknowledge that Lawlor Dermatology reserves the right to charge 100% of the desired service if I do not attend or cancel the scheduled appointment on the day of the scheduled appointment. I further acknowledge that Lawlor Dermatology reserves the right to reschedule my appointment if I am more than 15 minutes late to the scheduled appointment.