Patient Information

***PLEASE REMEMBER – to bring your Insurance Card(s), Medicare Card, Driver’s License, co-pay, and credit card, and a complete list of your medications***

(Failure to do so may result in the rescheduling of your appointment)

We confirm all appointments with automated calls.

I hereby give express consent to receive dialed, autodialed, pre-recorded or SMS Text calls from or on behalf of Orchard Park Dermatology at the telephone number(s) provided above. I understand that consent is not a condition of purchase or services received.

Office Policies and Financial Agreements

It is your responsibility to pay all co-pays, deductibles, co-insurance, and any non-covered or denied services.

If your insurance company pays the claim directly to you, please forward the check accompanied by insurance paperwork to our office.

• Co-pays need to be paid in full on the day of your appointment.
• Patients with a high deductible plan will be required to pay $50 for office appt. or $250 for surgery appt. on the day of the visit.
• You are responsible for the entire balance on your account at the time service is rendered unless we participate with your insurance company. Please discuss this with us in advance to avoid misunderstandings.
• You are responsible for cosmetic or non-covered services. Full payment must be made at the time of service.
• There will be a $75.00 fee for a regular visit and a $150.00 fee for a cosmetic visit on any appointment cancellation with less than 24hours’ notice or no-showing for a scheduled appointment.
• All product sales are final
• The charge for a returned check is $20.00
• Knowing I need a referral from my insurance company and obtaining the referral prior to my visit is my responsibility.

I authorize the release of medical information to my primary care or referring physician and as necessary to process insurance claims or prescriptions.

I understand that I am responsible for presenting a copy of correct and current insurance information prior to, or at the time of service. If the insurance information presented is incorrect, I am responsible for all charges incurred at the time of service.

I authorize payment of medical benefits to be made to Dr. Peter Accetta for all services furnished to me.

I have read the above Financial Policy and understand that I am financially responsible for all charges whether or not paid by my insurance. I understand and agree if the debt is not paid within (30) days, we will begin to incur an interest rate of 1.5% monthly or 18% annually until the debt is paid. I understand and agree if my account becomes overdue, it will be turned over to a collection agency, which may be based on a percentage at a maximum of 30% of the debt and all costs and expenses, including reasonable attorney fees and court costs we incur in such collection efforts. The agency or law office may report to one or more credit reporting agencies.

My signature constitutes my acknowledgment that I have been offered an opportunity to review the Notice of Privacy Practices from Orchard Park Dermatology, containing a more complete description of the uses and disclosures of my health information. This signature states an understanding of the above information and authorization for our medical personnel to examine and treat this patient, as well as authorizes release of medical information to the insurance company. I UNDERSTAND THAT THIS IS A LIFETIME SIGNATURE AUTHORIZATION.

CURRENT OR PAST PROBLEMS WITH: (Review of Systems)

Check Yes or No, explain as necessary

FAMILY HISTORY: Check following conditions that have occurred in your family.

Social History:

Consent for treatment

I hereby consent to all surgical procedures and treatment, including, but not limited to, any laboratory and biologic test and administration of anesthetics, which are deemed appropriate and necessary for the treatment of the disorder about which I have consulted this office (I understand that this consent does NOT limit my right to refuse any treatment or procedure if I so choose). I am aware that a scar may result from any surgical procedure I may have, and that the type of scar cannot be determined before surgery. I further agree that the information listed on this form that I have provided is correct to the best of my knowledge.

We confirm all appointments with automated calls.

I hereby give express consent to receive dialed, auto-dialed, pre-recorded, or SMS Text calls from or on behalf of Orchard Park Dermatology at the telephone number(s) provided above. I understand that consent is not a condition of purchase or services received.

Office Policies and Financial Agreements

It is your responsibility to pay all co-pays, deductibles, co-insurance, and any non-covered or denied services. If your insurance company pays the claim directly to you, please forward the check accompanied by insurance paperwork to our office.

• Co-pays need to be paid in full on the day of your appointment
• Patients with a high deductible plan will be required to pay $50 for office appt. or $250 for surgery appt. on the day of the visit.
• You are responsible for the entire balance on your account at the time service is rendered unless we participate with your insurance company. Please discuss this with us in advance to avoid misunderstandings.
• You are responsible for cosmetic or non-covered services. Full payment must be made at the time of service.
• There will be a $75.00 fee for a regular visit and a $150.00 fee for a cosmetic visit or a surgical visit on any appointment cancellation with less than 24 hours notice or no-showing for a scheduled appointment.

All product sales are final

• The charge for a returned check is $20.00
• Knowing I need a referral from my insurance company and obtaining the referral prior to my visit is my responsibility.

I authorize the release of medical information to my primary care or referring physician and, as necessary, to process insurance claims or prescriptions.

I understand that I am responsible for presenting a copy of correct and current insurance information prior to or at the time of service. If the insurance information presented is incorrect, I am responsible for all charges incurred at the time of service

I authorize payment of medical benefits be made to Dr. Peter Accetta for all services furnished to me.

I have read the above Financial Policy and understand that I am financially responsible for all charges whether or not paid by my insurance. I understand and agree if the debt is not paid within (30) days, we will begin to incur an interest rate of 1.5% monthly or 18% annually until the debt is paid. I understand and agree if my account becomes overdue, it will be turned over to a collection agency, which may be based on a percentage at a maximum of 30% of the debt and all costs and expenses, including reasonable attorney fees and court costs we incur in such collection efforts. The agency or law office may report to one or more credit reporting agencies.

My signature constitutes my acknowledgment that I have been offered an opportunity to review the Notice of Privacy Practices from Orchard Park Dermatology, containing a more complete description of the uses and disclosures of my health information. This signature states an understanding of the above information and authorization for our medical personnel to examine and treat this patient, as well as authorizes the release of medical information to the insurance company. I UNDERSTAND THAT THIS IS A LIFETIME SIGNATURE AUTHORIZATION.