PRIVACY POLICY NOTICES​ - Ginsburg Dermatology Center Notice of Privacy Policies that details how my personal health information may be used, disclosed, and my rights as permitted by federal law. As well I understand that this notice is posted for my benefit in the reception areas and on the website of Ginsburg Dermatology Center.

PATIENT RESPONSIBILITY - I understand that due to Federal (red flag) rules that Ginsburg Dermatology Center is prevented from filing my insurance without proof of identification. I will be expected to present a photo ID and insurance card(s) at every office visit. I will also update any changes to my addresses, telephone numbers, and insurance if they have changed since my last visit, and I understand I will be asked to update my demographics and signatures annually.

ASSIGNMENT OF INSURANCE AND FINANCIAL RESPONSIBILITY​ - I do hereby authorize payment of my insurance benefits, including authorized Medicare benefits, basic and major medical for the services I receive, to be made directly to Ginsburg Dermatology Center.

FINANCIAL RESPONSIBILITY - ​ I understand that although Ginsburg Dermatology Center will file a claim to my insurance plan(s), ​ I am expected to pay my copayment, coinsurance, deductible, and non-covered services amounts at the time services are rendered. ​ Because insurance policies vary greatly, we can only estimate the portion due in good faith. I acknowledge that Ginsburg Dermatology Center does not guarantee payment of my claim by my insurance plan and that it is my responsibility to know the provisions of my insurance. Not all procedures are deemed “Medical Necessity” by insurance carriers and can be considered cosmetic. For example-Skin, tag removal, correction of dark spots, yearly skin cancer screenings without specific areas of concern would not be a covered service. I understand I would be responsible for the payment of such services. I am ultimately responsible for any unpaid balance or non-covered service. I agree to pay all costs of collecting, securing, or attempting to collect or secure payment, including reasonable attorney fees or collection agency fees. I also understand any prior unpaid balances on my account must be paid in full before being seen by the provider. If my prior balance cannot be paid in full, I will speak with the billing department at Ginsburg Dermatology Center to make a payment arrangement before services are rendered. I also understand that if Ginsburg Dermatology Center does not participate with my insurance plan that, I will be expected to pay in full for my services. And it is my responsibility to know if Ginsburg Dermatology Center is in-network with my insurance plan. I understand that payments to Ginsburg Dermatology Center can be made by cash (please use correct change), checks, and all major credit cards. I also acknowledge that returned checks will be subject to a non-sufficient fund fee of $25.00.

UNINSURED - ​ I understand that​ ​ In the event I do not have health insurance coverage or my Insurance coverage becomes inactive, I will be responsible for services rendered at Ginsburg Dermatology Center. I agree to pay the practice the full amount for treatment given at each visit. (New self-pay patient appointments are ​ $ 98.00​ , and follow-up self-pay appointments are ​ $85.00​. ​ The self-pay charge covers your visit with the provider; however, if additional services (i.e., biopsies, freezing, in-office application of medication, etc.), there will be additional charges).

OWED BALANCES - ​ I understand that ​ ​ due ​ to ​ the high volume ​ of ​ unpaid patient balances, ​ it ​ is the policy of ​ GDC ​ to send only ​ three ​ statements. Statements are sent at 30​-​day ​ intervals. I understand if no payment ​ is ​ received ​ on my ​ ​ account during ​ the ​ 90​-​day ​ period​, ​ my accounts ​ will ​ be ​ turned ​ over ​ to ​ collection​s without additional notice. ​ I understand that If my account ​ is ​ turned over to a collection agency, I agree to reimburse GDC the ​ fees​, which may be based on ​ a ​ percentage at a maximum ​ of ​ 33% of the debt, and all costs, and expenses, including reasonable attorneys​' ​ fees we ​ incur ​ in such collection efforts.

APPOINTMENTS & CANCELLATIONS - ​ I understand that Ginsburg Dermatology Center strives to provide the highest level of patient care and respects the patient's time. We require a ​ 24 hrs notice. ​ It is the patient's responsibility to notify the practice at least 24 hours prior to your appointment. I am aware that Monday appointments must be canceled by noon on the previous Friday. I understand that if I miss my appointment without sufficient notification, ​ I will be charged a $50 fee. If I miss three appointments without sufficient notification, I will be dismissed from the practice for non-compliance​. I am also aware that if I run more than ​ 15 minutes​ late, I could lose my scheduled appointment time and will be asked to reschedule; this may also result in a ​ Late​ ​ Cancellation Fee of $50​ charged to you (not your insurance company).

REFERRALS/AUTHORIZATIONS - ​ I understand that if my insurance requires a referral or authorization, I am responsible for obtaining the referral prior to my visit. If I do not have a referral or authorization at the time of my visit, I will be rescheduled or, In such case you are seen, you understand your Insurance may not cover your visit; therefore, you will be held financially responsible for all charges billed for the visit. If your doctor wants to refer you for a test, or to another specialist, please allow​ 3 days for the medical staff to process your referral.

MEDICAL RECORDS - ​ All Medical Records are subject to a ​ fee​. Records can be faxed to another provider free of charge. Ginsburg Dermatology Center requires a 48-hour notice and a medical release form must be signed before any records can be released.

MEDICAL SERVICES - ​ I authorize Ginsburg Dermatology Center to render treatment to me or my dependents for dermatological care or medical procedures as deemed medically necessary for treatment as indicated.

COSMETIC SERVICES - ​ I understand that cosmetic services are not a covered benefit under insurance plans, and I will be expected to pay in full when services are rendered.

LIPO SERVICES​ - I understand that Lipo is not covered under insurance plans, and I will be expected to pay in full before scheduling my treatment. I​ also understand in order to reschedule or to receive a refund I must do so within three (3) normal business days before the day of my surgery.

LAB SERVICES - ​ I am aware that my laboratory/pathology services are not billed from Ginsburg Dermatology Center. I will receive a separate statement from the lab or pathologist. In addition, it is my responsibility to contact my insurance plan to determine what laboratory is in-network for my plan. LAB RESULTS can take anywhere to 3- 5 days. Lab or path Results that require additional treatment you will receive a phone call; all other results will receive a letter in the mail.

NO RECORDING -​ I understand​ ​ Ginsburg Dermatology Center prohibits the use of any recording devices in the waiting area or the exam rooms. Any unauthorized recording or photography may result in dismissal from the practice.

EMERGENCY ​ - I understand that the providers at GDC are only available during normal business hours. If you have a medical emergency, please ​ Call 911 or go to your nearest ER​.

MEDICATION - ​ I Acknowledge that

• Any​ ​ prescription refill request left for the assistant is reviewed at the end of the clinic each day. Once approved, your prescription will be called in. Please allow up to 24 hours.
  
  
• Any prescription refill request left after 3 pm will not be reviewed until after clinic on the next business day.
  
  
• Patients that have not been seen within one year will need to make an appointment to be seen for additional refills.
  
  
• When leaving a voicemail for the Assistant please leave your Full name, DOB, Medication name & dose, Call back number for the patient, Pharmacy name, and number. (any missing information could delay your request)

MEDICAL STUDENTS - ​ I understand that Ginsburg Dermatology participates in clinical education programs with area colleague's where Medical and PA Students engage in a course of study related to Dermatology in clinical practice. Ginsburg Dermatology has agreed to permit these students to observe and participate under his direct supervision to observe your examination/surgery when appropriate to participate. Patients do not have to participate in order to receive the treatment. I understand that if I do not wish to participate I will let the staff at GDC know at each of my visits

COSMETIC & MEDICAL PHOTOS

I hereby authorize the medical providers and staff of Ginsburg Dermatology Center to take ​ photographs, video or audio ​ that relates to my plan of treatment or care, and I hereby authorize GDC to use ​ photographs, video or audio​ for:

MINOR CHILD ​ - I understand that a parent or legal guardian must attend the initial appointment with the child and all appointments involving invasive treatments. Minor children must be accompanied by a parent or authorized individual age 18 or older for all appointments. In the event a parent cannot bring the child to subsequent routine appointments, a parent or legal guardian can execute the parental temporary assignment of authorization to treat the minor child

• If you wish to fill out the Minor child consent form Signatures must be witnessed by an employee at Ginsburg Dermatology Center.

I {patientName} parent or legal guardian of {parentOr246} do hereby consent to any medical care treatment determined to be necessary for the welfare of my child while said child is under the providers care at Ginsburg dermatology center and I am not reasonably available by telephone to give consent.

I hereby give Ginsburg Dermatology Center permission to

I hereby give Ginsburg Dermatology Center permission to disclose, discuss and speak to listed individual(s) concerning my medical or financial information including appointments, test results, prescriptions, school/work excuses, or ​ emergency situations​ etc. We must have each individual listed by name. This includes your spouse, children or parents.

Please have your INSURANCE CARDS and DRIVER’S LICENSE/ photo ID out and ready to be copied-Thank you!