New Patient Forms

I hereby give permission to Ohio Premier Dermatology to notify me by telephone of any appointment, message to call the office for test results (actual results will not be left) and other medical or cosmetic information

By signing here you give permission for your child, at least 16 years of age, to be seen without a guardian present.

The duration of this authorization is indefinite unless otherwise revoked in writing. I understand and authorize the release of this information to other health care providers associated with my care to facilitate further health care treatment. I further understand that requests for medical information from persons not listed above will require specific authorization prior to the disclosure of my medical information.

MEDICAL QUESTIONNAIRE

Medication

List ALL medications you are currently taking (including prescriptions, over the counter medications, vitamins, herbal supplements):

Social History:

Full Body Skin Exam: It is recommended you have a yearly full body exam for the detection and treatment of skin cancer. When scheduling this appointment please specify the appointment is for a full body exam as extra time is needed.

Ohio Premier Dermatology adheres to the following HIPAA guidelines set forth by the United States Department of Health and Human Services and the Office for Civil Rights. You have the right to receive, and we are required to provide you with a copy of the Notice of Privacy Practices (NPP). Below is a brief outline of the policies, but you are encouraged to read the full version.

HIPAA

The patient listed above or the legal representative of the patient listed above understands:

• Protected Health Information (PHI) may be disclosed or used for treatment, payment, health care operations, when required by law enforcement and for other legitimate reasons.
• We may contact you by phone, e-mail or in writing, to provide appointment reminders or information about treatments or other health-related benefits and services, in addition to other fundraising communications, that may be of interest to you. You do have the right to "opt out" with respect to receiving marketing and fundraising communications from us.
  Reminders of upcoming appointments may be left on an answering machine or with a family member.
• You have the right to request an alternative means of confidential communication.
• Your PHI will not be sold by Ohio Premier Dermatology
  You have the right to inspect, copy, restrict and amend your PHI or revoke prior authorizations in writing.
• You have the right to restrict disclosures of PHI to a health plan if the office visits or services were paid "out of pocket", in full and in advance or at the time of the visit.
• You have the right and will be advised if your PHI is intentionally or unintentionally disclosed.
• Uses and disclosures of PHI not described in the NPP will be made after written authorization form the patient

Notification regarding the availability of pathology or laboratory results may be left on an answering machine or with a family member BUT the actual results WILL NEVER be left to anyone other than the patient or family members) listed below.

Authorization for Disclosure of Medical Records

I authorize the disclosure of any of my medical records to the following individual(s):

Financial and Privacy Policy

One of our main goals here at Ohio Premier Dermatology is providing the best care and service with maximum satisfaction. For a better understanding of our financial and privacy policies, we have provided you with a copy of the practice's guidelines that we expect all patients to abide by.

By signing I hereby acknowledge receipt of Ohio Premier Dermatology's Notice of Privacy Practices, Financial and Practice Policies. I agree and will adhere to them when applicable.

Insurance Plans

Please make certain that you know what benefits are covered under your medical insurance policy. Your insurance policy is a contract between you and the insurance company and we are not a party to that contract. Please be familiar with your deductibles, co-payments, and percentages of coverage.
When reviewing your policy be aware that Ohio Premier Dermatology LLC is considered a specialist under most plans. To better determine your coverage provide your insurance company with the doctor's full name: Ramona Sarsama Nixon DO. or the Physician Assistant's full name: Eydie V. Mathews PA-C.
While Ohio Premier Dermatology is happy to submit claims to your insurance company on your behalf, payments for medical services provided are your responsibility.
Some policies will not cover the entire amount of services we provide. Your individual policy will determine the allowable reimbursement amount based on applicable contracts. If reimbursement does not cover our cost or coverage is denied, the remaining balance is your responsibility.

Self-Pay Patients

Payment is due at the time of visit for all services rendered. We offer a 20% discount for all self-pay patients who receive medical treatment from us. Payment is expected at the time of check-out to cover the office visit and any additional procedures. If further procedures are to be performed, the cost of the procedures will be discussed with the self-pay patient prior to performing them. The procedure will not be performed until payment is collected in full with the 20% discount included. We accept cash, check, and credit cards.

Patient Portal

In order to provide you with the best possible treatment, we are asking that each patient utilize the online portal to access your records. Visit ohio.ema.md and log in as follows:
Username: First initial of first name. last name date of birth Password: Last name.last 4 digits of SS#
Example: John M. Smith, Date of Birth 01/04/2009, SS# 123-45-6789
Username: j.smith010409 Password: smith.6789

Cosmetic Procedures and Non-Covered Services

Payment is due at the time of service. The patient is responsible for the payment of all cosmetic procedures and non-covered services performed. It is always the patient's responsibility to know what procedures are not covered under their insurance policy. Pre-payment may be required for some procedures.

Returned Checks

We charge a $25.00 service fee for any returned check. Any returned check must be paid within 10 days or the account may be turned over to a collection agency immediately.

Outstanding Balances

Unpaid balances must be paid in full before additional services can be provided, unless other arrangements have been made through our billing office. Balances over 90 days old will be assessed a $10.00 fee and turned over to an outside collection agency. Ohio Premier Dermatology reserves the right to terminate the patient-physician relationship due to unpaid balances.

Adult Students Covered by a Parent's Insurance Policy

If you are over the age of 18 and are currently on your parents' insurance, you are responsible for your bill. All co-payments are due on the day of service. We require your current address and your permanent billing address for our records.

Minors

A parent or legal guardian must accompany all children under the age of 18. We understand that there may be times when a parent/ guardian cannot accompany their teenagers or children to scheduled appointments. In those cases, we require a written consent from the parent/ guardian to treat the unaccompanied minor. In the case of divorced or separated parents, the parent who brings the child in for his/her appointment is responsible for the bill.

Medical Students and Photographic Images

Ohio Premier Dermatology has your consent to use the photographic images taken during your visit for educational or promotional purposes. You should understand that your identity will always remain anonymous. Ohio Premier Dermatology also has your consent to allow students in clinical areas to observe your visit. It is your responsibility to advise the provider or attending nurse in the event that you DO NOT consent to any of the matters above.

Medication Refill Policy

A patient who calls our office for a prescription refill can expect his/her medication to be ready at the pharmacy of choice in 24-48 hours unless told otherwise by our staff.

Late Policy

A patient who arrives ten or more minutes beyond his or her scheduled appointment time will be asked to reschedule. If you arrive less than ten minutes after your scheduled appointment, you will be seen when we are able to fit you in without interfering with other patients who have arrived on time. This may cause you to wait a considerable amount of time, so please be sure to always schedule your appointments appropriately.

No Show Policy

Any patient who fails to show up for their appointment more than two times will be forced to a more restricted schedule or discharged from the practice. Cancellation notices are requested 24 hours prior to the scheduled appointment time. If proper notice is not provided you will be charged $25 for a general appointment or $50 for a surgical appointment.

Termination of the Physician Patient Relationship

The physician is not compelled to treat every patient who requests treatment. Once a relationship is created, a physician has an obligation to provide services to a patient as long as required or until the relationship is properly terminated in accordance with Ohio Administrative Code Section 4731-27-01.
The physician has the absolute right to withdraw from the care of a patient for any reason, as long as the relationship is ended in an appropriate manner and for non-discriminatory purposes. When a physician/ patient relationship has been terminated, the physician will still continue to provide emergency treatment and access to services for up to thirty days from the date the termination letter was mailed.