Patient Registration

Office Financial Policy:

By signing this document, I am agreeing to the terms of this Financial Policy.

PAYMENT AT TIME OF SERVICE: Payment is due in full at the time of service unless you are covered by Medicare or an insurance company with which we participate. You will be charged a $25 service fee for any returned checks, no exceptions. Methods of payment accept are Cash, Visa, Mastercard, American Express, CareCredit, and Discover.

INSURANCE: Patients will be asked to present their insurance card to the receptionist for copying upon check-in at the office each time they are seen for medical services. Please make it a point to bring your insurance card with you each time that you visit our office. It is the responsibility of the patient to provide accurate insurance and personal information including any preferred laboratory cards. If your insurance requires a referral, it is your responsibility to provide the referral prior to your visit. You will be responsible at the time of service for the payment of copays, unpaid deductibles, and past due balances.

For those patients covered by insurance plans with which we ARE participating providers, all co-payments, deductibles and noncovered services are due at time of service. We will file the insurance claim to the insurance company. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service and we can file your claim to the insurance company as a courtesy. Any charges that are not paid by your insurance company are your responsibility. Your insurance policy is a contract between YOU and your insurance company. Any pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this.

SELF-PAY AND COSMETIC: Payment is expected in full at time of services - no refunds are allowed for performed services or consultations under any circumstance. Cosmetic and Medical Products: There are no returns accepted on any of our skin care products or medical products.

PATHOLOGY: is ordered by physicians to properly diagnose certain skin disorders. To increase the quality of care for our patients, we utilize a licensed lab SEPARATE from Chicago Skin Clinic. The analysis of these specimens is then performed by independent board-certified Dermatopathologists who specialize in this microscopic diagnosis of skin disorders. Charges for these services are IN ADDITION to your office visit charge and procedure charge. Please note that you may receive a separate bill for pathology services which will be billed to your insurance.

COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency. We send electronic invoices to your preferred email account and/or mailed statements. If no response is heard from you, your account will be referred to an outside collections agency for further processing.

CANCELLATIONS and MISSED APPOINTMENTS: We understand that unexpected events, illnesses, etc occur. When this happens, call our office as soon possible to inform us of such issues. In the case of missed appointments or cancellations within 48 hours of the appointment:
-Office Visit- I understand that it is my responsibility to cancel my appointment 48 hours in advance of my appointment time and date, otherwise a $75 fee will be billed to my account which is not covered by my insurance plan.
-Cosmetic Appointments- I understand that it is my responsibility to cancel my appointment 48 hours in advance of my appointment time and date, otherwise a $75 fee will be billed to my account.
-Surgical procedure appointments (dedicated surgical visit) - I understand it is my responsibility to cancel or change my appointment at least 48 hours prior to my appointment time and date, otherwise a $150 fee will be charged to my account which is not covered by my insurance plan.

MEDICAL RECORDS FEE:
The authorization for release of medical records will be provided to you upon request. A signed authorization is needed to release medical records and a new release is required every 12 months. Please allow 72 hours to process medical record requests after we have received your signed form. In some instances, there could be a fee required for the retrieval of your medical records. For FMLA forms, there is a $25 fee for completion of forms - this fee must be paid in full and is not covered by insurance.

CREDIT CARD AUTHORIZATION (CREDIT CARD ON FILE): I authorize Dr Del Campo and Chicago Skin Clinic to charge my credit card above for agreed upon purchases, patient responsibility for medical visits, patient responsibility for surgical procedures, no-show appointments fee, or services. I understand that my information will be saved to file for future transactions on my account. My information will be stored in bank level security using Square. This authorization will remain in effect until canceled.

Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.

By signing below, you acknowledge that you have received this notice and understand this policy.

 

AUTHORIZATION & AGREEMENTS OF MEDICAL TREATMENT

CONSENT FOR EXAMINATION I understand that an examination will be necessary, and I consent to the partial or complete examination as part of my medical care. I understand that the examination findings will be provided to me with recommendations. Results will be uploaded to the online patient portal, and it is my responsibility to access the portal and review them. I acknowledge that Chicago Skin Clinic will make reasonable efforts to contact me via phone, voicemail, or in-person visit to communicate results or follow-up recommendations. However, I understand that it is ultimately my responsibility to ensure follow-up by contacting the clinic if I do not receive results or cannot reach the clinic's staff. Danilo V Del Campo MDSC / Chicago Skin Clinic, or its assistants, will not be held responsible for ensuring follow-up care. I release the examining provider from liability except in cases of negligence or misconduct.

CONSENT FOR TREATMENT I hereby consent to and authorize the administration of diagnostic and therapeutic treatments, including but not limited to biopsies and cryosurgery, that may be considered advisable or necessary in the clinical judgment of Chicago Skin Clinic. I understand that I have the right to ask questions about the risks, benefits, and alternatives before undergoing any treatment. No guarantee or assurance has been given by anyone as to the results that may be obtained by such treatments.

CONSENT FOR ELECTRONIC COMMUNICATION I hereby consent and acknowledge that Chicago Skin Clinic will communicate with me by email and standard SMS messaging for various aspects of my medical care and billing, including test results, prescriptions, appointments, and invoices. I understand that email and standard SMS messaging are not secure methods of communication and that there is a risk of interception by third parties. Despite these risks, I prefer these communication methods for their convenience. I understand that I may revoke this consent at any time by notifying Chicago Skin Clinic in writing.

CONSENT FOR INFORMATION LEFT ON VOICEMAIL I hereby consent that telephone messages regarding my appointments, prescription renewals, lab results, and other protected health information may be left for me on my voicemail and/or answering machine. I understand that it is my responsibility to ensure the accuracy of the phone number I provide to Chicago Skin Clinic and to notify the clinic promptly if it changes. I consent that voicemail messages will include only the minimum necessary information to convey the purpose of the call.

CONSENT FOR PHOTOGRAPHY I hereby consent that Chicago Skin Clinic can take my photograph to incorporate into my electronic medical record. This photograph will be used for medical purposes by medical providers at Chicago Skin Clinic and will be securely stored in my medical chart. I understand that photographic images of lesions, biopsy or surgery sites, or cosmetic procedures will be taken for identification, insurance claims, and treatment progression purposes. I expressly consent to the use of these photographs for these purposes.

CONSENT FOR USE OF AI IN DOCUMENTATION
Chicago Skin Clinic uses secure, HIPAA-compliant artificial intelligence (AI) tools—such as Freed AI—to assist in real-time clinical documentation during your visit. These tools do not store information locally and use end-to-end encryption. By signing this form, you acknowledge and consent to this standard documentation method as part of your care.

CONSENT FOR BILLING AND FINANCIAL DISPUTES I authorize Chicago Skin Clinic to release information from my medical record, including but not limited to visit details and protected health information (PHI), for the purpose of resolving disputes related to card or bank chargebacks. I understand that only the minimum necessary information will be disclosed, and such disclosures will comply with applicable privacy laws, including HIPAA. This information will only be used to address the specific dispute and will not be shared for any other purpose.

GENERAL PATIENT RIGHTS I understand that I have the right to ask questions about my care, revoke consents provided in this document (except where required by law), and receive clear explanations of my responsibilities. Chicago Skin Clinic is committed to ensuring that I fully understand my rights and obligations related to my medical care.

 

Notice of Privacy Practices:
This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information, (PHI). PHI is information, including patient demographic information, that may identify you and that relates to your past, present or future physical or mental health and related health care services. Please review carefully.
Should you have any questions about this Notice, please contact our office and request to speak with the office manager.
We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. A copy is posted in our office and made available for patients upon request.

1. Permitted Uses and Disclosures
This practice may disclose protected health information on the individual who is the subject of the information for the following:
· Treatment is the provision, coordination, or management of health care and related services for an individual by one or more health care providers, including consultation between providers regarding a patient and referral of a patient by one provider to another.
· Payment encompasses activities of a health plan to obtain premiums, determine or fulfill responsibilities for coverage and provision of benefits, and furnish or obtain reimbursement for health care delivered to an individual and activities of a health care provider to obtain payment or be reimbursed for the provision of health care to an individual.
· Health care operations: (a) quality assessment and improvement activities, including case management and care coordination; (b) competency assurance activities, including provider or health plan performance evaluation, credentialing, and accreditation; (c) conducting or arranging for medical reviews, audits, or legal services, including fraud and abuse detection and compliance programs; (d) specified insurance functions, such as underwriting, risk rating, and reinsuring risk; (e) business planning, development, management, and administration; and (f) business management and general administrative activities of the practice, including but not limited to: de-identifying protected health information, and creating a limited data set.
· Business Associates: We may contract with individuals or entities known as Business Associates to perform functions related to payment and health care operations. In order to perform these health care operations on behalf of Chicago Skin Clinic, Business Associates are required, under legal agreement, to receive, create, maintain, use and/or disclose your protected health information only with appropriate safeguards regarding your protected health information. For example, we may disclose your protected health information to a Business Associate to administer claims or to provide support services, such as utilization management, pharmacy benefit management or subrogation. This is in compliance with HIPAA regulation 45 CFR 160.103, 45 CFR Part 160, 45 CFR Part 164.
· Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaver, organ, eye or tissue donation purposes.

2. Uses and Disclosures Which Require Your Authorization
· Marketing: As defined under the Privacy Rule, Marketing is communication about a product or service. Marketing may also be conducted with an arrangement between Chicago Skin Clinic and a third party whereby Chicago Skin Clinic discloses to the third party or its affiliates to make communication directly with patients for marketing purposes. This communication requires your written authorization either opting in to receive these communications or opting out.

3. Uses and Disclosures Which Do Not Require Your Authorization
Informal permission may be obtained by asking the individual outright, or by circumstances that clearly give the individual the opportunity to agree, acquiesce, or object.
· Emergencies: Where the individual is incapacitated, in an emergency situation, or not available, Chicago Skin Clinic generally may make such uses and disclosures, if in the exercise of their professional judgment, the use or disclosure is determined to be in the best interests of the individual.
· For Notification and Other Purposes: Chicago Skin Clinic also may rely on an individual’s informal permission to disclose to the individual’s family, relatives, or friends, or to other persons whom the individual identifies, protected health information directly relevant to that person’s involvement in the individual’s care or payment for care.
· Incidental Use and Disclosure: The Privacy Rule does not require that every risk of an incidental use or disclosure of protected health information be eliminated. A use or disclosure of this information that occurs as a result of, or as “incident to,” an otherwise permitted use or disclosure is permitted as long as the practice has adopted reasonable safeguards as required by the Privacy Rule, and the information being shared was limited to the “minimum necessary,” as required by the Privacy Rule.
· Public Health Activities: Chicago Skin Clinic may disclose protected health information to: (1) public health authorities authorized by law to collect or receive such information for preventing or controlling disease, injury, or disability and to public health or other government authorities authorized to receive reports of child abuse and neglect.
· Victims of Abuse, Neglect or Domestic Violence: In certain circumstances, Chicago Skin Clinic may disclose protected health information to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
· Health Oversight Activities: Chicago Skin Clinic may disclose protected health information to health oversight agencies (as defined in the Rule) for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.
· Law Enforcement Purposes: Chicago Skin Clinic may disclose protected health information to law enforcement officials for law enforcement purposes under the following six circumstances, and subject to specified conditions: (1) as required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests; (2) to identify or locate a suspect, fugitive, material witness, or missing person; (3) in response to a law enforcement official’s request for information about a victim or suspected victim of a crime; (4) to alert law enforcement of a person’s death, if the practice suspects that criminal activity caused the death; (5) when the practice believes that protected health information is evidence of a crime that occurred on its premises; and (6) by a covered health care provider in a medical emergency not occurring on its premises, when necessary to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.
· Serious Threat to Health or Safety: Chicago Skin Clinic may disclose protected health information that they believe is necessary to prevent or lessen a serious and imminent threat to a person or the public, when such disclosure is made to someone they believe can prevent or lessen the threat.
· Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
· Workers’ Compensation: Chicago Skin Clinic may disclose protected health information as authorized by, and to comply with, workers’ compensation laws and other similar programs providing benefits for work-related injuries or illnesses.

4. Your Rights
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
· Patient Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described. You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
· Access: Patient has the right to review and obtain a copy of their protected medical record. Chicago Skin Clinic may impose reasonable, cost-based fees for the cost of copying and postage of the record. Should the patient wish to review the record at the doctor’s office, every reasonable effort will be made to accommodate such request in a timely manner.
· Amendments: Patients have the right to request an amendment or correction to information within their medical record that is incorrect or incomplete. The physician has the right to deny said request and allow the patient in writing, to provide a statement of disagreement for inclusion in the record.
· Disclosure Accounting: Patients’ have the right to an accounting of the disclosures of their protected health information by the physician(s) of record. The maximum disclosure accounting period is the six years immediately preceding the account request, except that the physician(s) are not required to account for any disclosures made prior to the enactment of the Privacy Rule compliance date.
· Account of Disclosures that are not required of the physician(s): (a) for treatment, payment, or healthcare operations; (b) to the individual or the individual’s personal representative; (c) for notification of or to persons involved in an individual’s health care or payment for health care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (f) for national security or intelligence purposes; (g) to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or (h) incident to otherwise permitted or required uses or disclosures.
· Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500 et. seq. An individual has a right to or will receive notification of breaches of his or her unsecured PHI.
· You Have the Right to Request a Restriction of Your Protected Health Information. Under the Omnibus Rule, in subsection (vi) added to § 164.522(a)(1), a covered entity must honor an individual’s request to restrict disclosure of his or her PHI to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and the PHI pertains solely to a health care item or service for which the individual, or a person other than the health plan on behalf of the individual (such as a family member), has paid the covered entity in full.
You may also request that any part of your protected health information is not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by letter addressed to the Privacy Officer at your provider’s office.
· You Have the Right to Request to Receive Confidential Communications From us by Alternative Means or at an Alternative Location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact at our office.
· You Have the Right to Obtain a Copy of this Notice From Us, upon request, even if you have agreed to accept this notice electronically.

5. Complaints
Should you have a question, concern or complaint about the use of your PHI from this office, you are to contact our office. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of suspected violation. There will be no retaliation against any party filing a complaint.
Questions regarding this notice can be directed to:
Chicago Skin Clinic
ATTN: Privacy Officer
5440 W. Belmont
Chicago, IL. 60641
By Phone: (773) 286-8111

To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257 (or toll free (877) 696-6775) or go to the website of the Office for Civil Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against any party filing a complaint.
This Notice of Privacy Practices is effective January 1, 2024.

 

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

• a basis for planning my care and treatment;
• a means of communication among the health professionals who may contribute to my healthcare;
• a source of information for applying my diagnosis and surgical information to my bill;
• a means by which a third-party payer can verify that services billed were actually provided;
• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals

I have been offered and/or provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

 

HIPAA PRIVACY RULE OF PATIENT CONSENT AGREEMENT

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that:

• I have reviewed this facility’s Notice of Privacy Practices prior to signing this consent;
• This facility, reserves the right to change the notice and practices and that the most updated information can be seen in person at the office on request;
• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

Wonderful! Thank you for your asssitance!

You can call us at 773-286-8111 or visit us online at ChicagoSkinClinic.com

We look forward to your upcoming visit with us at:

5440 W. Belmont, Chicago IL 60641