ASSIGNMENT OF BENEFITS: The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to Polley Clinic of Dermatology. I understand that I am financially responsible for any balance. I also authorize Polley Clinic of Dermatology, its related companies to release medical information required to process claims and to release my medical record information to provide care. I authorize pictures of myself and of clinical focus areas to be stored in my medical record.
NOTICE OF PRIVACY PRACTICES: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established a Privacy Rule to help ensure that personal health care information is protected for privacy. The Privacy Rule was also created to provide a standard for certain health care providers to obtain their patient's consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.
HIPAA PRIVACY RULE: You will need to place a checkmark acknowledging the statements below:
- I have read the HIPAA Privacy Rule.
- I have received a printed copy of the HIPAA Privacy Rule.
- I have declined the offer to receive a printed copy of the HIPAA Privacy Rule.
PERSON/S AUTHORIZED TO ACCESS YOUR PROTECTED HEALTH INFORMATION (PHI) You will need to provide the name and the relationship to the patient of persons authorized to access the patient’s protected health information.
AUTHORIZATIONS: I authorize medical treatment of the person named above and agree to pay all fees and charges for such treatment. I understand that medical treatment may include a review of medical history, discussion of reason for the visit and medical photographs of the area being discussed. I authorize Polley Clinic of Dermatology and its related companies to disclose complete information concerning medical finding and treatment of the undersigned, from the initial office visit until date of the conclusion of such treatment, to those who in Polley Clinic of Dermatology’s determination, are required to receive such information for the purpose of medical treatment, quality assurance and peer review.
CONSENT TO TREATMENT OF A MINOR 16- AND 17-YEARS OLD: These patients MUST have a parent or legal guardian present for initial office visit, or they will be asked to reschedule their appointment. Patient’s 16 or 17 years old can be seen for follow up appointments without a parent or legal guardian only if the parent or legal guardian signs this consent authorizing Polley Clinic of Dermatology to provide treatment to their teen, which includes consent for physical exam, biopsy, and freezing treatments. I hereby grant Polley Clinic of Dermatology permission to treat my 16 or 17-year-old when they arrive at the office unaccompanied: Copay or Deductible amounts, Insurance cards, and Photo ID will be due at the time of visit. Please ensure that the patient and/or authorized person(s) are prepared to pay the amount designated by your insurance company.
CONSENT TO TREAT A MINOR: 15 YEARS OF AGE OF ALL OR YOUNGER: Minors 15 years old and younger MUST have an adult present for all office visits or they will be asked to reschedule their appointment. If the patient is 15 years old or younger, they will be able to be seen for their appointment with an adult present other than a parent or legal guardian only if the parent or legal guardian has filled out and signed this consent form authorizing Polley Clinic of Dermatology Surgery to provide treatment to their child. You will need to provide the name and the relationship to the patient of persons authorized to accompany the patient and grant Polley Clinic of Dermatology permission to treat the minor patient.
CONSENT FOR COMMUNICATION: I understand Polley Clinic of Dermatology will send appointment reminders and information on services via telephone, email and/or message based on the contact information I have provided. I understand that I will have the option to opt out of future communications on my behalf or the behalf of my dependents.
LEGAL GUARDIAN/POWER OF ATTORNEY
Due to HIPAA regulations, we are not allowed to release any medical information regarding medical condition, diagnosis, treatment, or prognosis regarding any patient to any person without written consent by the patient, legal guardian, or a person vested with power of attorney for the patient. You may designate a person or persons who are allowed to obtain this information in your absence by phone or in person. It is important for our office to have on record your designated person/persons to whom we can release medical information. If you are a Legal Guardian or have Power of Attorney for the patient, we require that a copy of the legal document establishing such status be on file with the patient’s records at Polley Clinic of Dermatology.
PAYMENT POLICY: Payment is due at the Time of Service including co-payments, deductibles, and balances due. I understand that I am responsible for all charges for services rendered on my behalf and the on behalf of my dependents, less any amount paid by my insurance to Polley Clinic of Dermatology. As of January 1, 2022, all patient responsible balances that are over 60 days old (2 statement cycles) will be assessed a late fee penalty of $25.00.
LATE OR MISSED APPOINTMENT POLICY: We require a 24-hour notice of cancellation if you are unable to keep your appointment. Should you fail to provide such notice, you will be classified as a NO-SHOW patient, and you will be charged a NO-SHOW fee of $50.
PERMISSION TO KEEP CREDIT CARD ON FILE
To Speed you through the check-in process, Polley Clinic of Dermatology can now keep your credit card information stored in our secure financial database.
Here are the advantages of allowing Polley Clinic to store your credit card information:
- The receptionist can automatically collect your copayment.
- For patients with high deductible plans, Polley Clinic can charge the card automatically when insurance has paid its portion of each claim.
- If you have a balance on your account this service will prevent you from receiving a bill or from your account being sent to a collection agency, should it become delinquent.
- You will provide us with the following information:
- Type of Card,
- Type Full Name of Card Holder
- Cardholder’s ZIP Code
- Last 4 Digits of Your Card Number
- Credit Card Security Code
- Credit Card Expiration Date.
PHOTO CONSENT & RELEASE FORM
I the undersigned do hereby allow a staff member of Polley Clinic of Dermatology or SkinCureOncology to take photos of my treatment. They will be placed in my medical record and used to document lesion locations, skin markings, and for monitoring my treatment progress.
You may also indicate the following preferences for the use of your photos:
- Advertising for Polley Clinic services
- To have your identity remain anonymous,
- To have your photos used for my medical record only.