Registration Form

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Patient Information

Insurance Information

In case of Emergency

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Nelson Dermatology or insurance company to release any information required to process my claims. By typing your name below, you are singing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Assignment & Release:

and assign directly Nelson Dermatology PLLC, all medical benefits, if any, otherwise payable to me for services rendered. I understand that I financially responsible for all charges whether or not paid by insurance. I understand my signature requests that payment is made and authorize the release of medical information necessary to pay the claim. I authorize the use to this signature on all insurance submissions. By typing your name below, you are singing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

I understand and agree that I am personally responsible for all charges incurred regardless of my insurance coverage in the event that my account is referred to an attorney for collections, I agree that in addition to the balance owed, I will be responsible for collection and attorney fees in addition to the balance owed. Payment for the services rendered or to be rendered in the future is irrevocably and unconditionally guaranteed by guarantor whose signature appears below, together with interest thereon and all late charges, attorney fees cost and expenses of collection incurred in enforcing any of such liabilities. I agree that all above information is correct to the best of my knowledge. By typing your name below, you are singing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Policies and Procedures Agreement

It is our goal to provide you the best dermatologic care we possibly can. Part of your care includes the billing of your insurance provided we’ve received the correct and complete information from you. If complete information is not provided at the time of your visit, you will be billed. Please read the following information as it will answer many of your questions regarding our billing policies.

All Patients: Are expected to have their current insurance card, valid picture ID, co-pay, co-insurance and any balance at the time of service.

HMO/Managed Care plans/Tricare: IT IS YOUR RESPONSIBILITY to make sure a current referral has been obtained prior to appointments with our office. If no referral has been obtained, you appointment will be rescheduled. It is THE PATIENTS RESPONSIBILITY to make sure the correct referral is in place if you are having testing performed. If you still desire to be seen without proper authorization, you will then be bound to our practice self-pay fees.

Co-pays: Primary and secondary insurance co-pays must be paid at the time of check- in. Patients will be asked to reschedule if they do not have their co-pay. If the co-pay is not paid at the time of visit there will be a $25.00 billing fee added.

Patient Information and insurance cards: Your personal information sheet and insurance card are an important part of your medical record. It is your responsibility to make sure that you update this information at each visit to keep your record current. As this may seem inconvenient, it is necessary to keep you insurance and contact information update to insure you receive proper care.

Late Policy: Every effort is made to keep our physician schedule on time, therefore if you are more than 15 minutes late, we will reschedule your appointment to the next available in the office; however, there is no guarantee that you will be seen immediately. If the physician schedule is full you will be asked to reschedule your appointment to a later date.

Transferring of Records: All patients must sign a records release form to have their records copied or to send them to another provider or organization. Copies will be provided to the patient for a $10.00 fee administrative fee PLUS $0.50 per page up to 50 pages and then $0.25 per page thereafter. There is no fee to transfer records directly to another provider or organization.

Collections: Patients that have an unresolved balance will be sent to collections. Patients will then accure an additional collection fees. Patients are expected to resolve all balances and /or collection issues before setting up their next appointment. Nelson Dermatology does not permit patients to carry balances. If patient balances are not addressed, patients are running a risk of being discharged from the practice.

No Shows: Failure to cancel an appointment within 24 Hours will result in a $50.00 no show fee and for any procedure that is not canceled you will be charged $75.00. Please remember a confirmation call is a courtesy done by this office and not an obligation, therefore will not be a reason to waive a no- show fee. I have read, understand and accept the above financial policy. Understand that charges not covered by my insurance company, as well as applicable co-payments, co- insurances and deductibles are my responsibility. I understand that it is my responsibility to contact my insurance carrier(s) if they do not respond to payment request made on my behalf. By typing your name below, you are singing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

HIPPA Authorization

I, the undersigned, authorize Nelson Dermatology PLLC to speak with the person(s) and/or Provider(s) listed below regarding my medical care. I understand that with my signature I am authorizing the release of written or oral communication by Nelson Dermatology PLLC to the listed person(s)/ provider(s) and thereby release Nelson Dermatology PLLC and their staff from all legal responsibility that may arise from the act hereby authorized:

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

I authorize Nelson Dermatology PLLC to leave a voicemail message at the following phone number(s):

Messages may at times include some protected health information, including appointment reminders, test results, instructions and any billing concerns. I understand that with my signature I am authorizing the release of oral communication by Nelson Dermatology PLLC to this voicemail number(s) and thereby release Nelson Dermatology PLLC and their staff from all legal responsibility that may arise from the act hereby authorized.By typing your name below, you are singing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

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Allergies to medication

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Health Habits and Personal Safety

ALL QUESTIONS CONTAINED IN THIS QUESTIONNAIRE ARE OPTIONAL AND WILL BE KEPT STRICTLY CONFIDENTIAL

Women Only

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