www.healthyskinmd.com -Patient Registration and History and Intake Form (NEW)

Patient Financial Liability Form
Insurance
Patients are responsible for providing accurate and timely insurance information to our office. Patients will be held financially liable for services rendered if the correct insurance information is not provided within the required filing period for their insurance. Verification of benefits or prior authorization is not a guarantee that an insurance carrier will pay a claim. The insurance carrier makes the final determination upon receiving the claim, based upon the plan's level of coverage and associated policies. Denied claims become the responsibility of the patient. Patients are fully responsible for obtaining any necessary referral from another physician before the appointment time. Insurance claims denied due to lack of referral will become the patient's responsibility.

Co-payments are due and payable at the time of service. If we are unsure of copay liability, we will bill the insurance first then the patient will be billed for any applicable co-payments. The patient agrees to pay all deductibles, coinsurance, and services deemed "patient responsibility" as identified by the insurance carrier. Payment in full is due upon receipt of the statement unless prior arrangements are made with the billing office.

Associates in Dermatology, Inc. accepts Visa, MasterCard, Discover, checks, or cash. Checks returned for nonpayment will be subject to additional fees. Unpaid patient balances may be placed with an outside Collection Agency if payment is not made within 90 days. This may adversely affect your credit. Non-emergent medical services may be denied until delinquent balances are paid.

Cosmetic Services

All Cosmetic services are payable in full at the time of service.

Biopsies / Pathology

A biopsy may be necessary during the course of your treatment. If a biopsy is needed, you will be billed separately by a Pathologist for the processing and interpretation of each specimen. We are unable to quote fees for pathology services.

No-Show Appointments

If you are unable to keep your appointment, please notify our office by phone or e-mail no less than 24 hours before your appointment. Messages are acceptable and can be left at all times, including evenings and weekends. Associates In Dermatology may assess a $75 fee for an appointment that is missed without adequate notice. I have read the above information and agree to the terms contained therein:
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Notice and Acknowledgement
I acknowledge that I have received the attached Notice of Privacy Practices.
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Privacy Policy
Associates In Dermatology is committed to respecting our visitors’ privacy and protecting their personal information from misuse or unauthorized disclosure and complying with privacy laws. Associates In Dermatology values its reputation and aims to maintain high ethical standards in the conduct of our business affairs.

Associates In Dermatology ("us", "we", or "our") operates www.healthyskinmd.com (the "Site"). This page informs you of our policies regarding the collection, use, and disclosure of Personal Information we receive from users of the Site. We use your Personal Information only for providing and improving the Site. By using the Site, you agree to the collection and use of information in accordance with this policy.
What information do we collect?
When filling in forms or calling the phone number listed on the website as appropriate, you may be asked to enter or provide your name, postcode and, email address and telephone number.

We will not collect any information about you without your explicit consent.

We will ask your consent every time we need to collect personal information about you.

We will explain in clear simple terms why we want to collect your information and what we will do with it, before seeking your consent, so you are fully informed. You will be given a clear and unambiguous option to opt in to any communications or services we might want to offer you.

All data is collected directly from you, the individual. We do not collect any of your personal data from any other sources. This includes any publicly accessible lists and or data sources, whether in the public domain or if we have a legitimate interest to be able to access those sources legally.
What do we use your information for?
Any of the information we collect from you may be used in one of the following ways:
- Identify you as a user in our system
- Provide you with the Services and complete your transactions;
- Provide you with customer support;
- Help understand your needs and tailor the features and content of the services to you;
- Respond to and, as applicable, fulfill your requests, resolve disputes and/or troubleshoot problems;
- Send you administrative e-mail notifications, such as security, or support and maintenance advisories;
- Send newsletters, surveys, offers, and other promotional materials related to our Services and for other marketing purposes;
- Improve the quality and functionality of the services;
- Share with our third-party software and services providers in order to facilitate our communications; and
  Communicate with you about our services.
- Any and all data in respect of – ‘What Information Do We Collect?’ is not subject to any automated decision
- making. We do not profile you using your data, any actions taken by us or our systems are as a direct result of explicit requests or consents you have chosen.
There are no foreseeable consequences of any significance in respect of providing the data or being removed from the records, except that we will not be able to contact you.
How do we protect your information?
We will store and process your data following industry best practices and security.

We will take all reasonable steps to ensure that there are appropriate arrangements in place that include provisions covering the appropriate secure transfer, handling and processing of the personal information by those entities and third parties.
Do we use cookies?
Yes. Refer our Cookie Policy. Visit: COOKIE POLICY
Do we disclose any information to outside parties?
We do not sell, trade, or otherwise transfer to outside parties your personally identifiable information. This does not include trusted third parties who assist us in operating our website, conducting our business, or servicing you. Where processing takes place by one of our trusted data processors, we ensure that our contracts with those third parties contain the appropriate GDPR / PIPEDA model clauses and that all our third parties are also compliant with the GDPR, PIPEDA this affords your data the same protection away from our organization, as it does within it.

We may also release your information when we believe release is appropriate to comply with the law, enforce our site policies, or protect ours or others’ rights, property, or safety. However, non-personally identifiable visitor information may be provided to other parties for marketing, advertising, or other uses.
Third party links
Occasionally, at our discretion, we may include or offer third party products or services on our website. These third-party sites have separate and independent privacy policies. We therefore have no responsibility or liability for the content and activities of these linked sites. Nonetheless, we seek to protect the integrity of our site and welcome any feedback about these sites.
Your rights as an individual in respect of the data we hold
We respect the rights and freedom of individuals and as such, we would like to make you aware of the following.

You have the right to:
- Request access to your data
- Request rectification of your data where there are errors or inaccuracies, or the data is not current
- Request that the data we hold is removed entirely from our systems
- Request us to restrict processing your data
- Object to our processing your data
- Request your data in a format that is commonly used/accepted
- Send your data to another controller
- Withdraw consent already provided – at any time
You also have the right to complain or withdraw your consent. To exercise your above rights, send a written request to policy@pri-pol.com
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Patient Registration Form

Emergency Contact

Guarantor Information/ Responsible Party

Primary Insurance Information

Secondary Insurance Information

History and Intake Form

Past Medical History

Past Surgical History

Skin Disease History

Current Medications

Allergies / Sensitivities

Social History

Quality Measures

Health Alerts

Patient Financial Liability Form

Insurance

Notice and Acknowledgement

Authorization to Disclose PHI (Personal Health Information)

Privacy Policy

What information do we collect?

What do we use your information for?

How do we protect your information?

Do we use cookies?

Do we disclose any information to outside parties?

Third party links

Your rights as an individual in respect of the data we hold