Thank you for choosing Dr. Shari Marchbein for your skin care needs. We are so excited to have you with us and dedicated to providing the best possible care and services for you. We deeply value you as a patient and appreciate that you have entrusted us with your health care. Completing the attached forms is necessary in order for you to be seen in our office. Please read each section carefully and sign where indicated.

 

OFFICE FINANCIAL POLICY:

Knowing your financial responsibility is an essential element of your care. With healthcare costs shifting to patient responsibility, it is essential you understand your deductible and details of your plan. Please read our financial policy carefully and sign at the bottom to confirm your understanding.

PAYMENT AT TIME OF SERVICE: Dr Marchbein is out of network with all commercial insurance plans. Payment for our services is due at the time of your visit. For patients who have Medicare, please bring your insurance card with you for each visit. It is the responsibility of the patient to provide accurate insurance and personal information including any preferred laboratory cards.

 

CREDIT CARD PAYMENTS: We use CardX to process our credit card payments. If you choose to pay by credit card, CardX will automatically apply a 3.0% credit card fee to your credit card payment. This fee goes directly to CardX and Niche Dermatology does not receive any portion of it. There is NO additional fee for the use of debit card, FSA, HSA, cash or Zelle, which you are welcome to use.

CANCELLATION AND MISSED APPOINTMENTS: We understand that unexpected events, illnesses, etc occur. When this happens, call our office as soon possible to inform us of such issues. In the case of missed appointments or cancellations within 48 BUSINESS HOURS of the appointment, a fee will be incurred. These fees will need to be collected before we are able to schedule you for another appointment. If you miss or last minute cancel 3 or more appointments, you may be asked to leave a non-refundable deposit prior to being able to schedule any further appointments.

 

For cosmetic appointments, if you No Show or cancel any portion of your scheduled procedure within 24 business hours of that appointment, you will be responsible for the full expected cost of the procedure you are canceling.

MEDICAL OFFICE VISIT: I understand that it is my responsibility to cancel or change my appointment at least 48 BUSINESS HOURS in advance of my appointment time and date, otherwise a $75 fee will be billed to my account.

SURGICAL/ COSMETIC VISIT: I understand it is my responsibility to cancel or change my appointment at least 48 BUSINESS HOURS prior to my appointment time and date. Otherwise a fee for any Cosmetic or Surgical appointment will be charged to my account. The fee for a 15 minute cosmetic appointment is $350 and for a 30 minute Cosmetic or Surgical appointment is $500. 

  
CREDIT CARD ON FILE: 

Shari Marchbein MD PC maintains a credit card on file for all patients. The card information is stored with security--the same HIPAA compliant software that protects your confidential medical information. Payment is expected in full at the time of service. You may use credit card, debit card, HSA/FSA card, Zelle, cash or check. 

For Medicare, it is our office financial policy to obtain your credit card number and authorization to process payment for charges not covered by your insurance carrier. We encourage our patients to understand their policy and to contact their insurance company for clarification of benefits prior to services being rendered. 

In providing your credit card information below, you authorize payment by credit card for services in the absence of coverage by your health plan, missed appointments and all uncovered medical services rendered by Shari Marchbein MD PC and received by you.

Please note that Shari Marchbein MD PC has the right to refuse medical services if credit card information is not provided.

 
By signing this document, I authorize Shari Marchbein MD PC to bill my credit card on file for cosmetic and medical services and acknowledge understanding of our Financial Policy and my financial responsibilities as a patient.

We thank you in advance for your cooperation and we look forward to taking care of you.

NO SHOW POLICY: 

We make every attempt to schedule patients at the earliest possible opening. Should you need to cancel or reschedule, it is very important you give us at least 48 business hour advance notice so that we can offer the appointment to another patient. In an event you are running late, please call our office. If you are more than 15 minutes late to your scheduled appointment, you may be asked to reschedule.

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Patients who do not show up for their appointment OR those that fail to cancel their appointment with at least 48 business hours notice, will be considered a no show. For Monday appointments, we kindly request that you cancel by the Thursday prior at 5PM to avoid the no show fee.

For any patient that fails to show or cancel with this advanced notice, we will charge a fee of: 

a) $75.00 for a missed Medical Office Visit

b) $350.00 for a missed 15 minute Cosmetic Visit

c) $500 for a missed 30 minute Cosmetic or Surgical Visit

 

CREDIT CARD PAYMENTS: We use CardX to process our credit card payments. If you choose to pay by credit card, CardX will automatically apply a 3.0% credit card fee to your credit card payment. This fee goes directly to CardX and Niche Dermatology does not receive any portion of it. There is NO additional fee for the use of debit card, FSA, HSA, cash or Zelle, which you are welcome to use.

Appointment reminders are sent via email 24 hours prior to your appointment as a courtesy. Failure to receive this reminder does not waive your responsibility of paying the no-show fee.

 

No Show fees will be billed directly to the patient. This fee must be paid in full at the time of the missed amount.

 

For cosmetic appointments, if you No Show or cancel any portion of your scheduled procedure within 24 business hours of that appointment, you will be responsible for the full expected cost of the procedure you are canceling.

Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.

By signing below, you acknowledge that you have received this notice and understand this policy.

CONSENT AGREEMENT:

CONSENT FOR ELECTRONIC COMMUNICATION: I authorize my physician and other staff at Shari Marchbein MD PC to send me text message appointment reminders and email appointment reminders to me on my provided cell phone and email address. This information will remain confidential. I understand that this communication will only include my appointment information and will not include medical information. I also authorize Dr Marchbein’s staff to enroll me in the office patient portal Weave, a HIPAA compliant app, which will allow for more efficient communication with our office. By signing below, I give my consent for this communication.

CONSENT FOR INFORMATION LEFT ON VOICEMAIL: I hereby consent that telephone messages regarding my appointments, prescription renewals, lab results and all protected health information may be left for me on my voicemail and/or answering machine. I hereby consent that the phone number provided by me to Shari Marchbein MD PC is accurate and up to date.

CONSENT TO BE PHOTOGRAPHED: I consent for medical photographs to be taken of me by the staff of Shari Marchbein MD PC. I understand that the images will be placed in my medical record and may be used for evaluation by employees of Shari Marchbein MD PC. By consenting to these medical photographs, I understand that I will not receive payment from any party. Although these photographs will be used without identifying information such as my name, I understand that it is possible that someone may recognize me. Photographic images will be taken of any procedures including biopsy and surgical sites, as well as all cosmetic procedures for the sole purpose of identification of said site, insurance claims, and treatment progression. I expressly consent to having said photograph taken.

I also give permission for transfer of these photographs via a non-encrypted email exclusively for the purposes of third-party diagnostics, treatment and continuing medical care (e.g. communication with another physician).

HIPAA PRIVACY RULE OF PATIENT AUTHORIZATION AGREEMENT:

Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as: 

• a basis for planning my care and treatment; 

• a means of communication among the health professionals who may contribute to my healthcare; 

• a source of information for applying my diagnosis and surgical information to my bill; 

• a means by which a third-party payer can verify that services billed were actually provided; 

• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals 

I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. 

HIPAA PRIVACY RULE OF PATIENT CONSENT AGREEMENT:

Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))

I understand that: 

• I have the right to review this facility’s Notice of Information practices prior to signing this consent; 

• This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested; 

• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested. 

• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon. 

• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

INSURANCE SIGNATURE ON FILE: 

Dr Marchbein is out of network with all commercial insurance plans. Payment for our services is due at the time of your visit. You can use your HSA or FSA card, if you have one. Or if you have out-of-network benefits, we will gladly provide you with a detailed itemized receipt after your visit, so you can submit to your insurance for potential reimbursement.

 

I certify that the information given by me in applying for Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of Medicare benefits, and I authorize payment of these benefits to Dr. Marchbein on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer of agency shown, and authorizes my doctor to act as my agent, as above.

Your signature below signifies that you understand Dr Marchbein is not in network with commercial insurance plans. For Medicare patients, your signature signifies that without a current copy of your insurance card, you will not be able to be seen or receive services from our office.