Amerejuve New Patient Packet

Authorization to release information: I hereby authorize the release to my insurance company of any information required in the course of my examination or treatment. This information may be released nor or in the future.

Authorization to pay Benefits to Physician: I hereby authorized and direct my insurance company to pay Amerejuve Dermatology any medical benefits which would be payable to me for their services.

I understand I am financially responsible for the charges not covered by this authorization.

Authorization for Medical Treatment: I authorize you to give me reasonable and proper medical care by today’s standards.

I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect the care I receive from the provider, my eligibility for benefits, or enrollment, payment or coverage of these services.

If applicable, legal representatives sign below:

By signing this form, I acknowledge that I am the legal representative of the member identified above and will provide written proof (e.g. Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the member’s behalf with respect to this authorization form.

In order to better serve our patients we have implemented an office policy regarding missed appointments. Your health is important to us and we hope to see you on your scheduled appointment. Our doctors have busy schedules with many people who need appointments. If you find that you are unable to keep your scheduled appointment, we request that you cancel or reschedule at least 24 hours in advanced.

Missed appointment or appointments not cancelled within 24 hours of the appointment will be charged a no show fee of $20.00, which must be paid before the patient may be seen again. Missed counseling appointments or counseling appointment not cancelled within 24 hours will be charged a no show fee of $50.00, which must be paid before the patient may be seen again.

Patient Financial Responsibility Policy

Thank you for choosing Amerejuve Dermatology Practice to serve the health care needs for you and your family. We are pleased to participate in your health care and look forward to establishing a lasting relationship as your health care provider. As part of this relationship, we have outlined our expectations for your financial responsibility in our Patient Financial Responsibility Policy. Please read this document thoroughly.

Insurance Policy:

• It is important for you to be an informed consumer who understands the specifications of your insurance policy (e.g., vaccine and doctor visit coverage, referral/authorization requirements for specialty care, radiographs, laboratory tests, urgent care facility care). Your health insurance policy is a contract between you and your Health Insurance Company or employer. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals, pre-certifications, pre-authorizations and limits on the outpatient charges regardless of whether or not our physicians participate in your plan.
• You must present a current insurance care at each visit. As a courtesy to you, we will bill your insurance company directly for medical services rendered. If problems arise regarding coverage issues, we will attempt to work with your insurance to help resolve them prior to making it your responsibility. However, please be advised that you are nevertheless ultimately financially responsible for payment of medical services rendered.
• If you do not present a current insurance care, you will be responsible for payment at the time of your visit. You will receive reimbursement from Amerejuve Dermatology if your insurance pays the claim at a later date.
• If you insurance carrier is not one with which we participate, you are responsible for payment in full.
• Insurance plans and Medicare consider some services to be “non-covered,” in which case you are responsible for payment in full.
• Accordingly, insurers are required to pay a properly submitted claim within 45 days. You have a responsibility to provide information to our office so a claim can be properly submitted. If your insurance company has not paid a claim on your behalf within 90 days, the balance will be transferred to your account and you will be responsible for payment. If we receive payment at a later date, you will be reimbursed. 
• If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, our-of-pocket fees and coverage limits.
• Amerejuve Dermatology contracts with many insurance plans. Before you appointment, please be sure your doctor is in-network and the services are covered under your plan, If you doctor is out-of-network, you may be responsible for a higher co-pay and/or deductible or you may be billed for the cost of care. 
• If we contact your insurance carrier regarding benefits or authorization on your behalf, we are not responsible for inaccurate information provided to us by your carrier. The information about your plan that we relay to you is in good faith and represents what the carrier has shared with us.

Address Change:

• It is important that we have your correct address information on file, please advise us anytime there is any change to your address, telephone or other contact information. We mail out lab results, pathology and appointment information in addition to billing statements to the address we have on file.

Co-payments, Deductibles and Co-Insurance:

• Co-payments are collected at the time of your visit at check-in. Insurance deductibles and fees for services nor covered by your insurance policy, if known, are due at the time the service is rendered, We accept cash, check and most major credit cards.

Billing:

• If you owe additional money after your visit, you can expect to receive a statement. Statements are mailed out on a monthly basis. Payment is expected within 10 days of receipt of your statement.

Failure to Pay:

• Patient who ignore collection notices and fail to pay their balance risk negative credit ratings and possible dismissal from the practice
• Past Due accounts may hinder your ability to have appointments scheduled.
• Should your account balance become uncollectible or if you file bankruptcy, we will continue to see you on an emergency basis only for 30 days, giving you time to find a new source of medical care.

Fees:

• Returned checks are subject to a $25 fee and your account will be placed on a “cash-only basis.” We will accept payments only by cash or credit card until the balance is cleared.
• Failure to give 24 cancellation notice or failure to keep your scheduled appointment may result in a charge of $20 for doctors’ appointment and $50 for counseling. Missed appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. We reserve the right to charge to charge a fee for canceled or missed appointments. If you must cancel an appointment, Amerejuve Dermatology requires a minimum of 24 hours notice.
• There is an administrative fee for completing forms such as DMV, physical forms, FMLA, leave of absence, disability etc. Most forms require 5 to 7 working days to research your information and completed the form.
• There may be additional charges applied to your account if we are asked to copy medical records per patient request or participate in a Deposition or Phone Consultation on your behalf.

Guarantor:

• Any patient over the age of 18, or an emancipated minor, will be held financially responsible for all charges incurred. If another party is responsible for payment of your account, you must pay your balance in full and negotiate repayment with them outside of our office. This policy includes negotiating divorce agreements.

Medicare Patients:

• Medicare may not cover some of the services that your doctor recommends. You will be informed ahead of time and given an Advanced Beneficiary Notice (ABN) to read and sign. The ABN will help you decide whether you want to receive services, knowing you are responsible for payment. You must read the ABN carefully.

Minors and Dependents:

• Parents and guardians are responsible for payments for the dependents at the time services are rendered. Minors and dependents must present a valid insurance card at each visit if a claim is to be filed. The accompanying parent or adult is responsible for full payment at the time of service, In cases of divorce, please do not place our office in the middle of marital disputes, It is your responsibility to work out the payment of your child’s medical care between the custodial and noncustodial parent.

Non-Emergency Appointments:

• Outstanding balances or failure to pay co-payments upon check-in may result in physicals and other routine or screening appointment to be rescheduled.

Prompt Payment:

• Just as we make every effort to accommodate you when you are in need to medical care, we expect that you will make every effort to pay your bill promptly. Payment is due at the time services are provided or upon receipt of a statement from our billing office.

Referrals and Authorizations:

• Please be aware of and provide any required referrals or authorization in advanced of the appointment of service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt contact your plan directly for clarification.

Refunds:

• A refund is issued when an overpayment has been identified. If you feel a refund is due, please contact our office

Self-Pay Patients:

• Self-Pay patient should be prepared to pay at the time of each visit.

Worker’s Compensation:

• The patient must provide at time of service: a claim number, name of the carrier, the date of injury, employer at time of injury and name and number of the claim adjuster. Without this information, the patient will be held responsible for all charges, and payment will be collected at time of service.

I hereby authorize Amerejuve Dermatology and its affiliates, employees, and agents to release information to:

My or my legal dependents person health information maintained by Amerejuve Dermatology (e.g., Information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided and which identifies me or my legal dependents name, address, social security numbers, member ID number) except the following information:

For legal proceedings, law enforcement, abuse, neglect, or public health safety or for the purpose of helping me to resolve claims and health benefit coverage issues. I understand that nay personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person or organization and may no longer be protected by applicable federal and state privacy laws; this authorization is valid from the date of my or my representative’s signature below. I understand I have the right to revoke this authorization by providing written notice. However, this authorization may not be revoked if Amerejuve Dermatology, its employees, or agents have taken action on the authorization prior to receiving my written notice. I also understand I have a right to have a copy of this authorization.

I authorize Amerejuve Dermatology to disclose my medical records to:

I authorized Amerejuve Dermatology to obtain my medical records from:

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully!

Protected health information about you is maintained as a record of you contacts or visits for healthcare services with our clinics. Specifically, “protected health information” is information about you, including name, address, phone, etc. that may identify you and relates to your past, present or future physical health condition and related health care services.

We are required to follow specific rules on maintaining the confidentiality of your protected health information, using your information, and disclosing or sharing this information with other health care professionals involved in your care and treatment. This notice describes your rights to access and control your protected health information. It also describes how we follow applicable rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our health care operations and of other purposes that are permitted or required by law. If you have any questions about this notice, please contact our Account Representative.

Your Rights Under the Privacy Rule

Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information. Please feel free to discuss any questions with our staff.

You have the right to receive, and we are required to provide you with, a copy of this Notice of Privacy Practices

• We are required to follow the terms of this notice, We reserve the right to change the terms of our notice at any time, If needed, new versions of this notice will be effective for all protected health information that we maintain at that time, Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment.

You have the right to authorize other use and disclosure

• You have the right to authorize or deny any other use or disclosure of protected health information that is not specified within this notice, You may revoke an authorization, at any time, in writing, except to the extent that your health care provider or our office has taken an action in reliance on the use or disclosure indicated in the authorization.

You have the right to designate a personal representative

• You may designate a person with the delegated authority to consent to or authorize the use of disclosure of protected health information.

You have the right to inspect and copy your protected health information

• You may inspect and obtain a copy of protected health information about you that is contained in your patient records.

You have the right to request a restriction of your protected health information

• You may ask us, in writing, not to use or disclose and part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care for notification purposes as described in the Notice of Privacy Practices, in certain cases, we may deny your request for a restriction.

You have the right to request an amendment to your protected health information

• You may request an amendment of your protected health information for as long as we maintain this information. In certain cases, we may deny your request for an amendment. You have the right to request disclosure accountability. You may request a listing of disclosures that we have made of your protected health information to entities or persons outside of our office other than for the purposes of treatment, payment, health care operations, or a purpose authorized by you.

How We May Use or Disclose Protected Health Information

Following are examples of uses and disclosures of your protected health care information that we are permitted to make.

Treatment

• We may use and disclose your protected health information to provide, coordinate, or manage you health care and any related services, This includes the coordination or management of your health care with a third party that is involved in your care and treatment, We may disclose protected health information to other healthcare providers who may be involved in your care and treatment, We may also call you by name in the waiting room when your health care provider is ready to see you. We may use or disclose your protected health information as necessary to contact you to remind you or your appointment. We may contact you by phone or other means to provide results from exams or treatments and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health related benefits and services offered by your office.

Payment

• Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.

Healthcare Operations

• We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. This includes, but is not limited to, business planning and development, quality assessment and improvement, medical review, legal services, and auditing functions, It also included education, provider credentialing, certification, underwriting, rating, or other insurance related activities. Additionally, It includes business administrative activities such as customer service, compliance with privacy requirements, internal grievance procedures, due diligence in connection with the sale r transfer of assets, and creating de-identified information.

Other Permitted and Required Uses and Disclosures

We may so use and disclose your protected health information in the following instance as outlined below. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.

To others involved in your healthcare

• Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, general condition or death. If you are not present or able to agree or object to the use of disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

As Required by Law

• We may use or disclose your protected health information to the extent that the law requires the use or disclosure.

For Public Health

• We may use or disclose your protected health information for public health activities and purposes to a health authority that is permitted by law to collect or receive the information.

For Communicable Diseases

• We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

For Health Oversight

• We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.

In Cases of Abuse or Neglect

• We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect, or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made in a manner that is consistent with the requirement of applicable federal and state laws.

To the food and Drug Administration

• Products: to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

For Legal Proceedings

• We may disclose protected health information in the course of any judicial or administrative proceedings, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized). In certain conditions in response to a subpoena, discovery request or other lawful process.

To Law Enforcement

• We may also disclose protected health information as long as applicable legal requirements are met for law enforcement purposes.

In Cases of Criminal Activity

• Consistent with applicable federal and state laws, we may disclose protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend and individual.

For 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 service.

For Worker’s Compensation

• We may disclose your protected health information, as authorized to comply with worker’s compensations laws and other similar legally established programs.

When an inmate

• We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you

Required Uses and Disclosures

• Under the law, we must disclosures about 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 the Privacy Rule.

Complaints

• You may address complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Risk Management and Compliance Department.

Our Notice of Privacy Practices provides information about how we may use and/or release your health information. You have the right to review our notice before signing this consent. You also have the right to refuse to sign this consent

If Applicable Name of Legal Representative:

Symptoms Check: Please select all the symptoms you currently have or have had in the past

Conditions: Please select all the conditions you currently have or have had in the past

Habits

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any error or omissions that I may have made in completion of this form.