Effective 11/29/2016
Unless other arrangements are made, payment for visit is due at the time of the service (either full fee if you are paying privately, or your co-payment if we are billing your insurance company). Insurance is billed as a service to our patients. I understand that all charges not paid by my insurance carrier(s) remain my responsibility. Office staff is available to discuss potential payment issues with you. Cancellation policy Twenty-four hour notice is required for a cancellation of scheduled appointments. You may be subject to a charge of the following fees for appointments that you “no show”: No show fee is $50.00. You are at risk of losing your privilege to receive care at Shenandoah Dermatology if you “no show” for two consecutive appointments. Please review the following:
In addition to the above financial statement, I have reviewed a copy of the HIPAA privacy policy posted in the main office and can receive a copy at my request.
*If patient is a minor, parent/legal guardian must sign and we must have the guardian’s SSN. I hereby give my permission to disclose personal health information about my treatment to the following individuals: (Example: Spouse, parent/legal guardian, friend, etc.)
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