Dear Patient:

We are very happy to welcome you to our Practice, and we are proud that you chose us to care for your medical needs. We will strive to make each and every visit a satisfying experience. For us to be successful in this endeavor, we must ask for your cooperation and understanding in not only supplying us with correct information but with our office policies as well. We hope that the following information is helpful in guiding you through your years as a patient of our Practice. We ask that you keep in mind that this letter in no way constitutes a contract between you, the patient, and the physician or the Practice, but instead serves as an outline for some of our more important policies that must be followed in order to keep our office open and available to our patients.

APPOINTMENTS:

We accept patients by appointment only. As a courtesy, appointments are confirmed prior to the visit via our automated system. We caution you not to rely on a confirmation from our office to remember your appointment, as you are still responsible for arriving on time or for canceling when you are unable to make your appointment. Our office utilizes an automated, pre-recorded appointment reminder service, and you may receive a phone call, a text message, and/or an email reminding you of your appointment. We are required by the Federal Communications Commission to notify our patients of and obtain express written consent for, the use of this service, which may remind a patient of their visit on the cell phone number provided to the office. Your signature (under separate cover) implies express written consent.

MEDICAL APPOINTMENTS Failure to arrive or to give a 24-hour notice for a canceled or request to reschedule an appointment will cause the patient account to incur a charge of $25.00 for established patients and $50.00 for new patients, for administrative fees. These fees are subject to change at any time and without written notice. Walk-in appointments are not recommended as they are very rarely able to be accommodated. We ask that you call to schedule your appointment during regular business hours. Appointments for multiple patients within the same family/scheduled appointment time will require a $25.00 deposit per family member. If the appointment is not canceled within 24 hours, the deposit becomes non-refundable. This deposit will be required at the time the appointment is made. A new patient that has previously no-called/no-showed for an appointment will be required to pay for a “99202 New Patient Office Visit ($125.00)” in full prior to re-booking an appointment. This balance will be credited to the account in advance of the patient visit.

COSMETIC APPOINTMENTS Failure to arrive or to give a 24-hour notice for a canceled appointment or request to reschedule an appointment will cause the patient account to incur a charge of $100 for administrative fees. These fees are subject to change at any time and without written notice. Cosmetic appointments include the following: botox, fillers, kybella, skinpen, facials, lasers, ultherapy and miradry treatments.

If you are late for your appointment, you may be rescheduled, or you may be seen on a work-in basis. Dr. Erwin tries to keep appointments on time, but on occasion, an emergency will occur. We are respectful of your time spent with us, and we try to avoid delays while caring for each patient’s needs. Occasionally emergencies or unanticipated issues arise, and we appreciate your patience during these rare occurrences. Please know that we will take care of you, too, when things get complicated!

It is very helpful for you to let us know why you need the appointment when scheduling so that we can allocate enough time for your needs. We perform cosmetic services at certain times, and these requests for treatment cannot always be accommodated if you attempt to add them to your appointment time. For example, fillers are time-consuming and will not be done outside of designated procedure times so as to keep our schedule running smoothly. You will be treated only for the problems for which you are scheduled.

Furthermore, only the patient scheduled will be treated. We ask that you not bring others into your appointment and expect to have them assessed or treated. Again, we are not often able to accommodate walk-in patients, and patients accompanying others into their appointments are considered walk-ins. We are always happy to make appointments for additional patients requiring treatment.

Our office utilizes mid-level providers (Nurse Practitioners and/or Physician Assistants), and when scheduling your initial or return visits, you will be given the option to see either Dr. Erwin or the mid-level provider. Mid-level providers are not physicians, and they function within the scope of practice appropriate for their license.

COLLECTION OF PERTINENT DATA

We must collect certain information from patients in order to file for insurance, while other information is collected as per office policy. All information collected is protected by HIPAA regulations, and when it is destroyed, it is done so in a secure manner. Once a year we will ask patients to update their demographic and medical information. It is highly recommended that if you have an extensive medication or past medical history list, you maintain your own typed copies of this and bring a copy to each of your visits.

PRESCRIPTION REFILLS:

Please contact your pharmacy and ask them to fax a refill request to 979-543-9959, allowing us 48 (business) hours for processing. In order for most topical prescriptions to be refilled, patients must be seen at least once per year. For prescriptions such as antibiotics to be refilled, patients must be seen at least every three months, or as directed by a physician. Accutane patients must be seen once per month during the course of treatment for the drug to continue to be prescribed.

FORMS & MEDICAL RECORDS:

Forms are subject to change at any time and without prior notice. Forms may change as a result of updated office policy or protocol or as a result of legislative changes. In order for us to release medical records to anyone other than the patient for any reason, the Practice requires that the patient complete the Authorization for Release of Protected Health Information. The Practice will not release any information without completion of this form by the party or legal guardian. Medical records that are printed and released to certain persons may be subject to charges that vary depending on the number of pages contained in the record. Patients are granted access to their own electronic health records via a patient portal.

TREATMENT OF MINOR PATIENTS:

Children under the age of 18 must be accompanied by a parent/guardian. If your child is to be treated without a parent/guardian present, a note must be presented to our office at the time that services are rendered. If you wish for your child to be treated without the presence of a parent/guardian, please sign below and return this signed form to our staff. Children must be 16 years of age or older to be seen alone.

FINANCIAL POLICIES

While we participate in most insurance and managed care plans, it is the responsibility of the patient to know their policy, what his/her policy covers, and that they may be responsible for non-covered services. Should the insurance company fail to make payment for any number of reasons, the amount owed will then be billed to the patient and due payable upon receipt.

All insurance-required referrals need to be received in our office prior to your visit. It is the PATIENT’S responsibility to obtain these referrals. Our staff strives to remind you that a referral is needed, but again, it is the patient’s responsibility to know his or her plan and to obtain referrals when required. We do not provide “wellness” or “preventative” examinations. When you are seen in our office, the appropriate-level office visit and/or procedure(s) will be billed to your insurance company or to you if you do not have insurance coverage.

If you do not have your original insurance card at the time of your appointment, you can choose to have your appointment rescheduled or we can collect in full for the services provided. It is imperative that you provide the correct insurance card at the time that the services are rendered. This is for YOUR protection so that you do not receive a bill for services that were not covered by the insurance due to the wrong insurance being filed.

WE DO NOT VERIFY BENEFITS PRIOR TO YOUR APPOINTMENT. Many of our procedures are performed on the day of the initial appointment. That is, we do not require an initial consultation followed by another visit for taking care of routine problems such as biopsies, warts, skin tags, etc. As such, it is not possible for us to verify benefits ahead of time, as we do not know what procedure is to be performed until the patient has been seen in the office. You are always welcome to ask about the cost and pricing for services when in the room with the provider prior to consenting to a procedure.

Many procedures, such as skin tag and wart removal, will require multiple treatments. Patients on Accutane must be seen once per month in our office and will need to have lab work as appropriate. You (or your insurance company) will be billed each time. We do not perform “warranty work.” If you are seen in the office, a charge will be generated. To eliminate billing errors, we utilize an intuitive electronic health record. By documenting your visits in this legal medical record, the appropriate charges and diagnosis(es) will be generated. This removes any human error from the equation and allows us to document and capture charges accurately.

If you are here for a cosmetic service such as Botox, filler, laser, or other procedure and you see Dr. Erwin or the mid-level provider for another reason such as acne, a spot of concern, etc., our documentation of your concern(s) in the legal medical record will generate the appropriate charge. This includes “just asking/showing” the provider other issues of concern. If you have insurance, this medical visit will be billed to the insurance. If you do not have insurance, the office visit and any subsequent procedure(s) performed will become your responsibility. As a courtesy to you, we will extend the self-pay rate to those without insurance coverage.

Payment is due at the time of service. A copay, if applicable, will be collected at the time of the visit. In the case of patients who do not have a copay listed on the insurance card, 20% of the visit will be collected as partial payment at the time that the services are rendered. Insurance will then be filed, and patients will be billed for any amount due over and above what was collected at the time of service. If you have met your deductible and annual out-of-pocket and feel that you should not owe the 20% of the visit, please notify us of this at check-out.

Patients who are self-pay will be responsible for the visit in full, at the time of service. We do offer a self-pay discount for those individuals without insurance coverage. Payment options include cash, check, all major credit cards, and Care Credit. Because we use an automated electronic health record, our charges do not pull through immediately. Often, the patient will arrive at the check-out window prior to the visit being finalized and the charges posted to the patient’s account. In the case of self-pay patients, we make every effort possible to collect in full, though there are times that charges for procedures or other services have not been finalized prior to the patient leaving. In these instances, the patient may receive a statement after the fact.

Once payment is determined to be the responsibility of the patient, a first billing statement will be sent to the address of record. Payment is due upon receipt. Should you be unable to make payment at this time, please contact our office at 979-543-9933 to make payment arrangements. If there is no contact with or payment made to our office, a second statement will be issued. If there is still no contact with or payment made to our office, a third and final notice will be sent. If the final notice goes unheeded, the account will be turned over to an outside collection agency and due process will begin. Our office makes every attempt to notify you of a balance due on your account, however, the final responsibility for payment rests with the patient or the responsible party. Patients that have been turned over to collections are no longer able to be seen in the office. We are happy to transfer your records to another provider of your choosing.

Our staff is always available and happy to speak with you should you have questions about your account. You can be assured that you will be treated with respect, and we will strive to eliminate any concerns that you may have. In return, you are expected to treat our staff respectfully, even if you disagree with your bill. We will work to get to the bottom of any issue that you are having, but this office will not tolerate belligerent or abusive language toward our staff. If you are belligerent, abusive, or rude to staff, we reserve the right to terminate the patient/provider relationship.

Again, thank you for allowing us to take care of your dermatological and cosmetic needs. We look forward to a long and mutually-beneficial relationship. We greatly appreciate your understanding and cooperation with our office policies and procedures. Please do not hesitate to reach out to our office staff if you have questions or concerns. The most efficient way to contact us is through your patient portal.

Sincerely,

The Practice of Erwin Dermatology

The Practice of Erwin Dermatology, Medical & Cosmetic Dermatology, reserves the right to refuse service to any person that chooses not to follow our office policies and procedures or terminate the care of any patient who repeatedly demonstrates adverse behaviors that place the patient’s medical status at risk and/or threatens health center operations, or the health or well-being of other patients and/or staff. We do not tolerate rudeness or abusive language. If you feel that you have not been given the friendly treatment that you deserve, please let Dr. Erwin or the Practice Manager know.

 

Revised April-23