NEW PATIENT PACKET

Emergency Contact Information

Insurance Responsibility

If yes, move onto next section. If no, please answer the following questions.

Referring Physician Information

(If applicable)

Office Policy

Please remember that insurance is considered a method of reimbursing the patient for fees paid to Levy Dermatology, P.C. and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charges. In order to control the cost of billings, we request that charges be paid at the conclusion of each visit. I am aware that my insurance copay, deductible, and/or coinsurance is to be paid at each date of service. If my insurance plan requires an authorization for this visit and any follow up visits, it is my responsibility to ensure that the referral is current and on file with Levy Dermatology, P.C. IT IS MY RESPONSIBILITY TO PAY ANY COPAY, DEDUCTIBLE, COINSURANCE, AND/OR OTHER BALANCES NOT PAID BY MY INSURANCE COMPANY. I am aware that if Levy Dermatology, P.C. does not participate with my plan or if I have no insurance, payment in full must be made on the date of service.

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

Patient History

Dermatology:

REVIEW OF SYMPTOMS (Do you have any of the symptoms below? Please check Yes or No).

1. Constitutional

2. Eyes

3. ENT

4. Cardiovascular

5. Respiratory

6. Gastrointestinal

7. Genitourinary

8. Musculoskeletal

9. Neurological

10. Psychiatric

11. Endocrine

12. Hematology/Lymph

13. Immunologic

14. Gynecological (Women Only)

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

Patient Financial Policy

In order to provide understanding between our patients and the practice, we have implemented the following financial policy. If you have any questions about the policy, please ask to speak with someone in our billing department. We are committed to providing you the best possible care and your complete understanding of your responsibilities are a key element in providing that service.

• A driver’s license, or other state-issued photo ID, is required to be shown at your visit to verify that we are providing services to the appropriate person and protect our patients from identity theft.
• For all services rendered to minor patients, we will hold the parent or legal guardian accompanying the minor on the first visit responsible for the expenses occurred.
• If you fail to notify us of an insurance change you will be fully responsible for any amount not paid by your insurance company.
• Commonly, in this practice, we perform surgical procedures that require lab work. The laboratory company will bill your insurance and a separate statement will be sent to you for their services.
• Past due accounts may be referred to a collection agency. Additional fees may be incurred when accounts are sent to collections, and you may be reported to credit reporting agencies. Offices visits are at risk of being terminated when non-payment is a persistent issue.
• Out of courtesy to others, we ask that you kindly give at least a 24-hour notice for cancelling an appointment. You will be responsible for a $35 charge for general appointments and an $80 charge for surgeries and/or cosmetics for no-show visits or cancellations less than 24-hour notice.
• Cosmetic appointments/concerns are subject to an $80 consultation fee. All payments towards cosmetic appointments are due at the time of service.

Patients Filing with Insurance (General Dermatology/Surgery Patients ONLY):

• Knowing about your insurance coverage is your responsibility and you may contact the insurer for coverage questions. It is always best to ask questions about your insurance coverage PRIOR to having services performed.
• Co-pays, deductibles, and coinsurances are required at the time of service. We accept cash, credit, debit, and care credit.
• You are responsible for any services that your insurance does not cover at the time of service.
• As a courtesy, we will file an insurance claim with your insurance company. If your insurance company has not paid the claim within 45 days you will be responsible for payment.
• Your insurance policy is a contract between you and your insurance company in which the doctor is not involved.
• Note: Even though a service is “covered” by your insurance policy, this does not necessarily mean that your insurance will pay for the service. If you are unsure of your responsibility, please contact your insurance company prior to your visit or having any procedures done.
• If any claim is not covered after processing through your insurance company, you are responsible for the unpaid balance.

Patients with Insurances we DO NOT participate with and/or Self-Pay Patients (General Dermatology/Surgery ONLY):

• Payment in full is required at the time of service. We accept cash, credit, debit, or care credit.
• If you have received authorization for services from our practice that are not normally covered by your plan, please note that payment is still due at time of service, and we will file a courtesy claim for you.

I have read and understand the financial policy of Levy Dermatology, P.C. and agree to its terms. I understand that such terms may be amended by the practice at any time.

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

Notice of Privacy Practices and Patient Consent For Use and Disclosure of Protected Health Information

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain Patient Rights regarding my protected health information.

I understand that Levy Dermatology, PC may use or disclose my protected health information for treatment, payment or health care operations—which means for providing health care to me, the patient; handling billing and payment; and, taking care of other health care operations. Unless required by law, there will be no other uses and disclosures of this information without my authorization.

Levy Dermatology, PC has a detailed document called the ‘Notice of Privacy Practices’. It contains a more complete description of your rights to privacy and how we may use and disclose protected health information.

I understand that I have the right to read the ‘Notice’ before signing this agreement. If I ask, Levy Dermatology, PC will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Levy Dermatology, PC to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Levy Dermatology, PC has taken action relying on this consent.

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

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our ‘Notice’ at any time by contacting: Levy Dermatology, PC 6254 Poplar Avenue Memphis, TN 38017 Phone: (901) 624-3333 Fax: (901) 624-1203.

Medical/Surgical/Cosmetic Skin Care Specialists

CONSENT FOR CARE

I hereby give by consent for treatment at Levy Dermatology, P.C.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Levy Dermatology, P.C. to release any information acquired during my examination or treatment to third party payors for payment of the charges. I authorize the release of any information necessary to expedite insurance claims.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY

I have received a copy of the Notice of Privacy Practices as required by HIPAA Privacy Regulations, developed 2013.

ELECTRONIC PRESCRIBING

I authorize Levy Dermatology, P.C., its employees or agents, to release Medical Information to share and/or receive prescription information electronically via SureScripts for my treatment medication

PHOTOGRAPHY

Photographs are often necessary for documentation of medical, surgical, and cosmetic procedures. I understand that the photographs are subject to the same highest level of confidentiality, privacy, and security as my other medical records. By consenting to these medical photographs, I understand that I will not receive payment from any party and that all identifiable features of the photograph will be concealed to the best of our ability.

By checking more than medical chart below, I understand that should my image be selected for publication, the image may be seen by members of the public in addition to students and medical researchers. Every effort to conceal identifiable features of the photo will be made. I understand, however that it is possible that someone may recognize me, and I hold Levy Dermatology and Dr. Levy harmless for any consequences of my identification. I understand that once photographs are released to social media, it is impossible to control them and their use/distribution.

I give my permission for medical photographs to be made of me. I understand that the information may be used in my medical records, for medical teaching purposes, for publication in medical textbooks or journals, and/or in media as I have designated below.

By signing below, I confirm that this consent form has been explained to me in terms that I understand. I consent for my photographs to be used for (Please place a check mark in EACH BOX indicating your consent):

Authorization to Leave Messages

Please place a check mark in EACH BOX indicating your consent:

Please provide a list of anyone besides yourself who has permission to receive information regarding any of the contents of your medical record.

By signing below, I understand that I may revoke this authorization at any time by notifying the clinic in writing. The revocation will only be effective from the date it is received in this office and will not apply retroactively.

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