Administrative Policies

CONSENT TO TREAT AND FINANCIAL RESPONSIBILITY
 

By my signature, I voluntarily give my informed consent for myself and/or my child and/or my ward to be examined and treated by the physicians and staff at Essential Dermatology, including medical evaluation, treatment, and related procedures that are necessary in the judgment of the Practice. I acknowledge that no guarantees have been made to me concerning the results of outcomes of evaluations, tests, treatments, or procedures. I understand that the Practice may find that additional evaluations, tests, or procedures are necessary for my care. I understand that I am ultimately responsible for following the instructions of the Practice and for having any recommended evaluations, testing, or procedures performed. I understand that by signing this form, I am authorizing the Practice to treat me for as long as I seek care from the Practice, or until I withdraw my consent in writing.

 

By my signature below, I hereby assign to the Practice the right to receive payment of benefits for any service rendered to me by the Practice. I understand that I am financially responsible to the Practice for services I receive which are not covered under my health insurance. I hereby certify that the information given by me in applying for payment under any State or Federal health care program (including but not limited to Medicare and Medicaid) or submitted by me to my insurance carrier(s) is complete, accurate, and correct.

Mass General Brigham Health

Financial Agreement with NWC ESSENTIAL DERMATOLOGY 

Essential Dermatology, PLLC / Essential Dermatology NWH PLLC / Essential Dermatology BILH, PLLC

ESSENTIAL DERMATOLOGY is devoted to providing you with the best possible care.  If you have health insurance, we are committed to helping you receive your maximum allowable benefits. We must emphasize that as health care providers, our relationship is with you, not your insurance company. The filing of insurance claims is a courtesy that we extend to our patients; all charges are your responsibility from the date the services were rendered.

·        I understand that I am financially responsible for any services not covered or allowed, but not paid due to the terms of my insurance coverage.  I understand that it is my responsibility to comply with the guidelines set by my insurance company.

·        I understand that all co-payments, deductibles, and non-covered charges are due at the time of service.

·        I accept full responsibility for payment of services and/or for securing necessary primary care referrals or pre-approval for medical visits.  If applicable, I understand that I have an obligation to obtain a referral for specialist services from my primary care physician (PCP) prior to having services rendered.  I acknowledge that if the appropriate referral/authorizations are not on file at the time services are rendered, that I am financially responsible for any charges denied by my health insurance carrier as a result.

·        I accept that a cancellation fee of $100 will be charged for any missed appointment if 24 hours’ notice is not given, or for arriving significantly late for my appointment(s), unless acceptable documentation of an emergency is provided.

·        If uninsured, full payment for all services is due on the date of service.  I understand that future appointments may be contingent upon having met my financial obligations within the office, or having made appropriate arrangements with NWC ESSENTIAL DERMATOLOGY.

·        If the visit is a work-related injury, I acknowledge that it is my responsibility to obtain an authorized claim number from my employer's worker's compensation insurance carrier and maintain approval for every visit.  I am financially responsible for all non-authorized charges.

·        I hereby authorize payment directly to NWC ESSENTIAL DERMATOLOGY for services rendered otherwise payable to me.  I authorize release of information required to complete insurance claims.  

 

HIGH DEDUCTIBLE PLANS: Special Notice

Essential Dermatology, PLLC wants patients to be fully informed regarding the specific benefits afforded to subscribers by their health insurance carriers. Specifically, patients with high deductible plans should take notice of their carrier's policies regarding out-of-pocket costs and deductibles. 

For example, if a subscriber's (patient's) health insurance plan has a $2000 deductible, before reaching the $2000 deductible, this individual will likely be responsible for ALL charges associated with a given visit to Essential Dermatology per the carrier's policies. With any questions regarding your specific plan's benefits, please reach out to your carrier directly.

 My signature below affirms that I have read and agree to the above statements and have accepted responsibility for all fees incurred for my medical care. 

 

Mass General Brigham Health & Essential Dermatology, PLLC Privacy Practices

·        220 North Main Street, Suite 201, Natick, Massachusetts 01760

·        340 Maple Street, Suite 202, Marlborough, MA 01752

·        145 Rosemary Street, Suite C, Needham, MA 02494

Essential Dermatology, PLLC and Mass General Brigham are an integrated health care system, which includes all the entities listed on the back of the Privacy Notice.  These hospitals and entities, as well as the doctors, nurses, therapists, and other providers of health care who work in these organizations, are called “providers.”  These providers may share patient health information for treatment, billing, and health care operations.

 

Federal law requires that all patients be given a copy of the MGB HealthCare Privacy Notice.  The Privacy Notice describes in detail how patient health information is used and shared with others.

 

MGB HealthCare has reserved the right to change the Privacy Notice at any time.  You may obtain a current copy of the Privacy Notice by contacting the admitting office, the registration office, your doctor’s office, or by going to the MGB Web site:

 

https://www.massgeneralbrigham.org/content/dam/mgb-global/en/notices/documents/hipaa-privacy-notice-en.pdf

 

All reasonable efforts will be made to protect the privacy of patient health information, whether it is maintained on paper or electronically, and regardless of how it is communicated, for example, by e-mail or facsimile mail.   

 

Additional languages:

Espanol:

https://www.partners.org/Assets/Documents/Notices/Partners-Urgent-Care-Privacy-Policy-Spanish.pdf

 

Portuguese:

https://www.massgeneralbrigham.org/content/dam/mgb-global/pt-br/notices/documents/hipaa-privacy-notice-pt-br.pdf