First Visit Form

Parent or Responsible Party
Is the responsible party the same as the patient? *

Yes No
Name

First Name Last Name
Relationship
Mailing Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
DOB

Month Day Year
mm-dd-yyyy
Home Phone Number
Cell Phone Number
Work Phone Number

Consent for Treatment of Minor Child

ONLY COMPLETE IF THE PATIENT IS A MINOR AND YOU ARE THE PARENT/GUARDIAN
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
mm-dd-yyyy
I, being the parent or guardian of {patientName181}, do hereby request and authorize the physicians and staff of Dermatology and Mohs Surgery Center, PC, to perform necessary services for my child which are deemed advisable by the physician, whether or not I am present at the actual appointment. A parent/guardian who brings a child to our office for medical care is responsible for payment of all of the child’s charges.
Below is the list of individuals who have permission to bring my child for treatment:
Signature of Parent or Guardian *

Clear

Emergency Contact Information
Name *

First Name Last Name
Relationship *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Cell Phone Number
Work Phone Number

Primary Insurance Information
Do you have insurance? *

Yes No
Subscriber's Name *

First Name Last Name
Subscriber's DOB *

Month Day Year
mm-dd-yyyy
Relationship to Patient *

Self Spouse/Partner Child/Dependent
Insurance Carrier *
ID # *
Group #
Effective Date

Month Day Year
Date
Referral Required *

Yes No
Employer *
Front of insurance card - upload an image

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Back of insurance card - upload an image

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Secondary Insurance Information
Do you have secondary insurance? *

Yes No
Subscriber's Name *

First Name Last Name
Subscriber's DOB *

Month Day Year
mm-dd-yyyy
Relationship to Patient *

Self Spouse/Partner Child/Dependent
Insurance Carrier *
ID # *
Group #
Effective Date

Month Day Year
Date
Referral Required *

Yes No
Employer *
Front of insurance card - upload an image

Browse Files
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Back of insurance card - upload an image

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Medical History: Women Only
Pregnant

Yes No
Due Date (if pregnant)

Month Day Year
Date
Breastfeeding

Yes No

Pharmacy Information
Pharmacy Name
Pharmacy Phone Number
Pharmacy Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Release of Information
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
Date
May we leave a message on your answering machine or voicemail regarding test results? *

Yes No
May we leave information regarding your medical care with someone other than you? *

Yes No

Please indicate with who we can leave a message regarding appointments and test results:

Name

Relationship

Phone Number

Contact 1

Contact 2

Contact 3

Patient/Representative Signature *

Clear

Receipt of HIPPA Policy:
I acknowledge I have received or declined a copy of Dermatology and Mohs Surgery Center, PC's Notice of Privacy Policy. This policy is posted in the waiting room and is available from our receptionist or on our website at www.dermatologyandmohs.com.
Patient Name *

First Name Last Name
Patient DOB *

Month Day Year
Date
Patient/Representative Signature *

Clear

Medicare Patients
Our practice is a participating provider with Medicare. We will accept assignment on all claims. Patients are responsible for their yearly deductible and 20% portion of your bill not covered by Medicare. Our office is required to keep your signature on file authorizing us to file claims to Medicare on your behalf. By signing, you are authorizing Dermatology and Mohs Surgery Center, PC to release medical and/or other information to the Social Security Administration and Health Care financing Administration as needed for this or related Medicare claims. You are permitting the use of a copy of this authorization in place of the original and request payment of medical insurance benefits to either our practice or the party that accepts assignment. Regulations pertaining to Medicare assignments of benefits apply.
Patient Name

First Name Last Name
Patient DOB

Month Day Year
Date
Patient/Representative Signature

Clear

Financial Policy

Thank you for choosing Dermatology and Mohs Surgery Center, PC as your healthcare provider.

If you have health insurance coverage:	If you do not have health insurance coverage or if you request a cosmetic procedure:
You are responsible for supplying us with current, correct insurance information	Payment in full is due at the time of service.
Please notify us of any changes in your address or telephone number.	We accept cash, Visa, MasterCard, Discover, and American Express
You are ultimately responsible for payment of all charges whether or not such charges are covered and paid (either fully or partially) by your insurance company.	Patients scheduled for surgery must submit check payments 14 business days prior to surgery. Cash, Visa, MasterCard, Discover, or American Express payments must be submitted 7 business days prior to surgery.
Referrals (for HMO patients) are your responsibility and must be current prior to your visit
All co-pays and your estimated portion, including any deductibles and/or co-insurances, will be expected at the time of service.
You may not self-pay, and then ask us to file your insurance at a later time.

Our business office is availabe from 8a-4p, Monday through Thursday and 8a-2p on Friday to answer any questions or address any concerns you have. If you receive a statement from our office, then we expect payment from you. If you disagree with the balance for any reason please contact our business office immediately at (215) 345-6647. A $35.00 fee will be charged on all returned checks.

I hereby guarantee payment of all charages for medical treatment and services provided to me (or my dependent) by Dermatology and Mohs Surgery Center, PC. I understand and agree that if the office places my account with an agency or attorney for collection, the offices shall be apid by me for all collection costs to the extent allowed by applicable law. I authorize the release of medical information to my primary care or referring physician and to consultants if needed and as necessary to process insurance claims, insurance applications, and prescriptions. I also authorize payment of medical benefits to the physician. I have read and agree to this financial policy
Patient/Representative Signature *

Clear
Card on File
By signing below, I authorize Dermatology and Mohs Surgey Center, PC to keep my credit card information securely on-file in my account. I acknowledge that if I receive a statement outlining any balances not covered by insurance, I authorize DMSCPC to charge my credit card for that outstanding balance if it is not paid within 30 days of receipt of my statement. You will not receive any additional notification prior to your card being charged after 30 days. If the credit card that I give today chagnes, expires, or is denied for any reason, I agree to immediately give DMSCPC a new, valid credit card which I will alllow them to charge over the telephone. Even though DMSCPC is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.
Patient/Representative Signature *

Clear
To Our Patients
We have implemented a convenient payment policy using a credit card to be held on file effective December 2019. As you may be aware, the current healthcare market has resulted in insurance plans increasingly transferring costs to you, the patient. Many insurance plans require deductibles, coinsurance and/or copays in amounts that are unknown to you, or to us, at the time of your visit. Our patients will be asked for a credit card at the time of check in. Your card information will be held securely until your insurances have paid their portion and notified us of the amount you owe. Any remaining balance owed by you will be charged to your card on file and a receipt will be emailed to you.

Our electronic health record stores card information via X2 Payments System, Inc. a secure credit card processor. Office personnel will not have access to your card information. Only the last 4 digits of your card will show in our system. A valid credit card, debit card, HSA or FSA card will be accepted.

Cards on File will be used for:
- Copays – When you come into the office, we will ask you if you want to use your card on file to pay your copay for today’s visit. You may choose to present another card if preferred, or any other form of payment accepted by our office.
- Deductibles – Your card on file will be utilized to settle any deductible amount due after your insurance plan has paid their portion for your visit or service. It is always a good idea to contact your insurance plan to determine how much of your annual deductible has been met, prior to each visit.
- Co-Insurance – Your card on file will be utilized to pay for your percentage not covered by insurance and not paid at the time of your visit or service. For example: If your insurance covers at 80% we will require the 20% balance be paid after your insurance has paid their portion.
- Outstanding Balances – If your account has a previous outstanding balance, your card on file may be used to settle that outstanding balance. If the outstanding balance is too large for one transaction, a payment plan may be worked out.
The Financial Policy you signed when you enrolled with our practice covers this change as it already states that “Payment is due when services are rendered”. This is just another form of collecting that payment.
Nothing is changing about how much you pay. When you come to our office and receive a service, you do so with the understanding that you are ultimately responsible for the cost of your care.

This notice is available on our website and presented to our patients at check-in. See the attached Frequently Asked Questions for more information.
Frequently Asked Questions
Why the change?
Nothing is actually changing about how much you pay. When you come to our office and receive a service, you do so with the understanding that you are ultimately responsible for the cost of your care. With the changing environment in healthcare, in particular more high deductible health plans, more responsibility of payment is being placed on the patient. We need to be sure that patient balances are paid in a timely manner. To do this, we need to ensure we have a guarantee of payment on file in our office. We have wonderful patients and we know most of you pay your balances. Unfortunately, that is not always the case. Although this is surprising to you, we are not the first medical practice to enforce this policy and you will begin to see it more and more.

What are the benefits to me?
Convenience: Patients who have a credit card will no longer have to worry about statements and mailing in payments. You can also use it to pay for future visits without having to bring your card to each visit. Having a credit card on file will make check-in and check-out easier, faster and more efficient for patients. Our office staff can spend our time on things we think are more important, like following up with insurance claims, helping patients on the phone and in person and working to make your visit the best it can be.

How does this work?
At check-in, we will ask you to sign a “Card on File Agreement”. We will only charge the amount that we are instructed to by your insurance plan in the explanation of benefits (EOB) that they send to us, after your visit. If the payment is declined, we will request updated card information or an alternative form of payment.

What if I do not have a credit card?
If you do not have a valid credit card, a debit card, health savings account (HSA) card or flexible spending account (FSA) card are also accepted.

What about identity theft and privacy?
Under HIPAA, we are under strict state and federal guidelines to protect patient privacy and your card on file is considered protected health information. X2 Payment Systems, Inc., our credit card processing vendor will store your information on a secure and encrypted site, which will enable us to run bank card transactions through our computer system. Office personnel will not have access to your card information. Only the last 4 digits of your card will show in our system.

I’ve never had to do this before at any other doctor’s office.
This may be different from what you have been used to, but it is not uncommon in many medical practices, imaging centers, outpatient surgical centers and outpatient laboratories to require a card on file. This is similar to hotels and rental car agencies that require a credit card to be kept on file.

What if I need to dispute my bill?
We will always work with you to understand if there has been a mistake. Should your card be mistakenly run, we will refund your card. We will only charge the amount that we are instructed to by your insurance plan in the EOB they send to us.

What if I have more questions?
Our staff is available to speak with you about your account at any time during regular business hours.
Patient/Representative Signature *

Clear

Patient Information

Parent or Responsible Party

Consent for Treatment of Minor Child

Emergency Contact Information

Primary Insurance Information

Secondary Insurance Information

Medical History

Medical History: Women Only

Pharmacy Information

Release of Information

Receipt of HIPPA Policy:

Medicare Patients

Financial Policy

Card on File

To Our Patients

Frequently Asked Questions

Cosmetic Questionnaire