I hereby consent to the use and disclosure of personal health information by Ohio Dermatology Center and its workforce, and its business associates for the purposes of carrying out treatment, health care operations, and obtaining insurance payment. A copy of the Notice of Privacy Practices for Protected Health Information (Privacy Notice) has been made available to me and it describes my rights as well as the potential uses and disclosures of my protected health information by Ohio Dermatology Center.

• You have the right to revoke this consent at any time by notifying the office in writing, except to the extent the office has taken action and reliance upon your consent.
• You have the right to request to restrict the manner in which your protected health is used. The office is not required, however, to agree to such requested restrictions. If the office agrees to the requested restriction, our office will honor the request and it will be binding.
• We have reserved the right to change the privacy practices described in the Privacy Notice in accordance with the law.
• You may obtain a copy of the Privacy Notice and revisions by making such request in writing or in person at our office.

I, the undersigned, have insurance coverage with and assign directly to Ohio Dermatology Center medical benefits, available to me via my medical insurance coverage. I understand that I am financially responsible for all charges whether or not paid by said insurance, unless assignee has executed an agreement with my insurance provider or plan. I understand that if such agreement has been executed, I am responsible to pay any deductible and/or co-payment and non-covered services under the terms of my insurance. I understand that I am financially liable in the event of non-payment: I agree to pay the collection agency's cost and/or court cost and reasonable attorney fees.

I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of Medical or other information about me release to the Social Security Administration, Medicare, or its intermediaries or carriers, any and all information needed for this or related Medicare claim. I authorize and request that payment be made directly to Ohio Dermatology Center.

Some insurance companies require a referral to see a specialist for any reason. It is your responsibility to call your insurance company to determine if a referral is needed. If a referral is required, you must have your primary care physician complete the referral prior to your visit. If a referral is not completed, you have two options: sign a waiver agreeing to pay for services at the time of your appointment or reschedule your appointment allowing time for a referral to be completed.

Ohio Dermatology Center is not responsible for knowing your insurance policy and what services are eligible for coverage. You must contact your insurance company to determine what your policy will cover.
Please understand that the billing staff of Ohio Dermatology Center will file all claims for covered services with your insurance company if the treating physician is a contracted provider. By signing, you are stating that you understand that you are responsible for any balance that may be due to the physician as a result of:

• Co-insurance or co-payments
• Annual deductible amounts
• Non-covered services
• Out-of-network charges
• Terminated coverage
• Exhausted benefits
• No insurance coverage
• Failure to respond to insurance company correspondence or inquiries
• Fees related to non-payment, missed appointments, returned checks and others
  

Please read and sign this statement before we agree to accept assignment of benefits directly from your insurance company. This avoids any misunderstandings and facilitates the processing of your insurance claim.

MEDICARE: We are participating providers of the Medicare program. We will accept assignment of all claims. Patients are responsible for meeting their annual deductible and co-pays at the time of service.

HMO, PPO, or OTHER MANAGED CARE PATIENTS: You will be responsible for paying your annual deductible, co-payment and charges for any non-covered cosmetic services at the time of service. Patients without the required referral from your PCP at the time of appointment will be asked to reschedule. If you prefer to be seen without the required referral, payment will be due at the time of service.

COMMERCIAL INSURANCE PATIENTS: Patients who are covered by private, commercial plans, in which our physician is not contracted, are responsible for all fees. The balance left after payment from your insurance will be billed to you.

MEDICAID WAIVER (All forms of Medicaid): Ohio Dermatology Center does not accept Medicaid or any forms of Medicaid. I understand Ohio Dermatology Center will not bill Medicaid, therefore if I have one of these insurances as my primary insurance I will be responsible for my entire bill at the time of service. I understand that if one of these insurances is my secondary, I will be responsible for the amount my primary doesn’t cover. At my request Ohio Dermatology Center will provide an estimate prior to receiving my services.

I understand and agree that if a check is returned for insufficient funds, the office will only accept cash or credit card payment on my account thereafter and I will be obligated to pay a returned check fee of $50.00.

I understand that filing claims with my insurance company or other third party payer, under any circumstances, does not relieve me from my responsibility for the payment of all charges. I further acknowledge that I am responsible for the payment of all charges for services rendered by Ohio Dermatology Center to me or the patient indicated. By signing this document, I personally guarantee the payment of these charges for medical services rendered. I agree that this authorization shall be valid until rescinded in writing or replaced by one of a later date.

I understand that I will receive a statement for any balance due after the claim has been processed by the insurance company. I understand and agree that the balance on my statement will be paid in full to the physician within 60 days. If the balance is not paid within 30 days, I understand that my account will be subject to the collection process, including the collection fee, and that I may be turned away for non-emergent service until the balance is paid.

Should you be unable to keep your appointment, please contact the office to cancel your appointment. Failure to contact the office with at least 24 hour advance notice will result in the following fees: Office visit- $50.00, Procedure- $50.00, Surgery- $100.00, and Mohs surgery- $150.00. This fee is not reimbursable by your insurance company.

** See cosmetic services financial form for cosmetic cancellation fees**

There is a copying charge to the patients leaving the practice for producing copies of medical records in ordinance with Ohio regulations (ordinance # 3701.741).

 

** We accept most major credit cards including CareCredit for your convenience.**
**There will be a $35 charge for all checks returned for insufficient funds.

 

I have read, understood, and accepted these policies,

1. I request and authorize medical or surgical treatment as may be deemed necessary and appropriate by the physicians and hi/her designees and assistants participated in my care. This care may include surgical and laboratory procedures; local anesthesia; therapeutic procedures; and medications. I know procedures that have more risk will be explained to me so I can give informed consent for them. I know I can ask my doctor any question(s) I have about my treatment.

2. I authorized Ohio Dermatology Center to release pertinent information and/or copies of medical records for treatment, payment, or health care operations purposes. I understand such information may include human immunodeficiency virus (HIV), AIDS related complex (ARC), acquired immunodeficiency syndrome (AIDS), hepatitis, and substance abuse, if any.

3. I understand and agree that, in accordance with State law, an HIV, HBV, or HCV tests may be performed upon me in the even a health care worker sustains a significant exposure to my blood or bodily fluids. The results of any test will be treated confidentially.

4. I authorize Ohio Dermatology Center to retain, preserve, or use for research, scientific, scientific or teaching purposes, or to dispose of any specimen or tissue remaining after completion of a clinical procedure or treatment.

5. I release Ohio Sermatology Center from responsibility for all personal articles which I have with me during the time I am at Ohio Dermatology Center. I understand that Ohio Dermatology Center is not responsible for clothing, eyeglasses, denture, jewelry, money or any other personal articles of value kept in my possession while at Ohio Dermatology Center.

6. Title 42 CRF 420 requires that a physician notify the patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the non-routine goods or services being prescribed by the physician, and if these are available elsewhere on a competitive basis. We support this law because it helps patients make reasonable financial decisions concerning their medical care. In compliance with the requirements of this law, we have a direct financial interest in the diagnostic or treatment agency or in the non-routine good or services: Pathology Services. These services are available elsewhere on a competitive basis at various hospitals and surgical centers in Franklin County such as Mount Carmel East Hospital.

7. In accordance with Federal Law, Ohio Dermatology Center is notifying you that it will not honor advanced directives.

8. Under the Federal Law Health Insurance Portability and Accountability Act restricts Ohio Dermatology Center from discussing any medical information, unless a release form is signed.

 

• I read this form or it has been read to me and I am satisfied that I understand its contents. I further understand that this consent will be deemed continuing and I am free to withdraw my consent at any time. 
• I received a copy of the Notice of Privacy Practices and Patients’ Rights and Responsibilities.
• I acknowledge the Direct Financial Interest Disclosure.
• I consent to pictures or videos being recorded or televised during my treatment, including appropriate portions of my body, for medical research or educational purposes, as long as my identity is not compromised or released.
• I agree that you may call me on whatever phone numbers I give you, including land lines, cell phones, Skype numbers, or anything else.

I, {patientName}, whose signature appears below, authorize Ohio Dermatology Center and its affiliated providers to view my external prescription history via the RxHub service.

I understand that the prescription history from multiple other unaffiliated providers, insurance companies, and the pharmacy benefit managers may be viewable by my providers and staff here, and it may include prescriptions back in time for several years.

My signature certifies that I read and understood the scope of my consent and that I authorize the access.

If any prescriptions are written during your visit for convenience purposes we will E-prescribe them directly to your pharmacy.

Ohio Dermatology Center is not responsible for knowing your insurance policy and what services are eligible for coverage. You must contact your insurance company to determine what your policy will cover. Cosmetic procedures are not covered by most insurances.

• There is a $100.00 fee for all cosmetic consultations due at the time of scheduling. This fee is nonrefundable.
• Procedure estimates are valid for 90 days from the date of your consultation.
• A 50% deposit of the cosmetic procedure must be paid when scheduling. The remaining 50% deposit of the cosmetic procedure must be paid one week prior to the appointment.
• You must notify us at least 48 hours in advance if you are unable to attend your appointment to avoid a $100.00 fee deducted from your deposit.
• No shows will forfeit all payments.
• If you wish to cancel your procedure, you must cancel at least a week before the scheduled date and you will receive the 50% deposit you paid, or you can use it on other services.
• Cosmetic procedures can only be rescheduled once.
• Charges for pre- and post-procedural prescriptions are not included in the cosmetic fee.
• Charges related to any procedural complications resulting in additional care and/or hospitalization will be your responsibility.
• Acceptable forms of payment are cash, personal check, all major credit cards, or CareCredit. Payments can be made over the phone with Ohio Dermatology Center staff, with a credit card on file, or in the office.

I have read this entire document and have been given the opportunity to review and discuss the fee(s). I understand my financial obligations set forth herein. I understand that the procedure(s) is/are cosmetic and not covered by my insurance plan. My signature below is a statement of my understanding of and agreement with the information set forth on this document.