AUTHORIZATION:
I (parent/legal guardian name) First Name* Last Name* request and authorize McLean & Potomac Dermatology and Skincare Center and its personnel to deliver medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of a minor child.

I am also aware that, in addition to making medical decisions on my behalf, that the adult presenting the child is responsible for payment of the patient portion at the time of service.

I have the legal right to preauthorize McLean & Potomac Dermatology and Skincare Center and its personal to deliver medical treatment and services to my child. Medical care and interventions may include, but are not limited to: medical evaluation, physical exam, or lab work. (Examples include, prescriptions, blood tests, biopsies, culture swabs, urine tests, wart treatment and liquid nitrogen, minor suturing after biopsies, etc.)

I have read, understand, and give my consent as stipulated above. My signature means that I have read this form and/or have had it read to me and explained in the language that I can understand. 

At McLean and Potomac Dermatology and Skincare Center, we are committed to providing the best dermatologic care.

This agreement must be signed in order to be seen by providers at McLean and Potomac Dermatology and Skincare Center.

OFFICE POLICIES

A. In fairness to all patients, we ask that you be on time for scheduled appointments. Every effort will be made to accommodate patients who arrive more than 15 minutes late, however, to maintain the flow of patients on time for their appointment, you may have to wait in the waiting room longer and/or the appointment may need to be rescheduled for another time.
B. There are fees for all services performed by our providers and staff, including consultations and procedures.
C. As the patient or guarantor, you are responsible for all charges for your visits, including co‐payments at the time of service, deductibles, and coinsurance amounts that are due per your insurance plan. 
D. Our office policy requires a credit card to be stored on file for all patients. This card will only be charged by the billing department for outstanding balances remaining after insurance payments have been processed and three statements have been mailed to the patient. 
E. Cosmetic services cannot be processed through insurance, and fees for such services are due at the time of service. All sales are final.
F. If there is a balance due after insurance pays for your visit, the difference owed is patient responsibility.
G.Charges for all visits and procedures that are not processed by insurance are due at the time of service.
H. If you have an outstanding balance on your account, it must be paid in full prior to your appointment.
I. We accept cash and all major credit cards. We do not accept checks as a form of payment in office.
J. Credit card payments may be subject to additional processing fees at point-of-sale.
K. For any mailed NSF check (checks returned for non-sufficient funds), a $50 NSF charge will be billed to your account.
L. If proof of insurance is not provided at the time of service, you are responsible for the entire fee for the consultation and/or procedure at the time of service.
M. In the case of an account overpayment, a credit will remain on your account unless you request a refund. 
N. Test results and records for patients 18 years and older will not be released to anyone other than the patient without a signed release form.
O. There is a $20.00 administrative fee for a copy or transfer of records. Our medical release form can be found by texting our HIPAA compliant system Klara located on our website or the form can be completed in office. Once we receive the request, the forms will be texted to you. Please allow 5 to 7 business days for the transfer of records.
P. By providing your mobile number, you consent to receive appointment reminders, billing notices, and other communication via SMS text messages. You may opt out of SMS communications at any time.

 24-HOUR CANCELLATION/RESCHEDULING POLICY

Reminder calls and text messages are sent out as a courtesy; however, it is the responsibility of the patient to remember appointments. 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. A no-show fee of up to $150.00 for appointments will be incurred if the appointment is not cancelled at least 24 hours in advance. Outside of operating hours, rescheduling and cancellation requests can be made via voicemail or our texting system Klara. Requests made outside of operating hours will not incur a fee if compliant with the 24-hour window. Specific rates are determined based on appointment types and times. Further details can be found on the financial policy page.

  MINOR (UNDER 18) POLICIES

A. If a child is accompanied by an adult other than a parent or legal guardian, a consent form must be authorized by a parent or legal guardian. Patients under 18 years of age should not be present for services unless accompanied by an adult, have a signed authorization on file, or in instances where treatment is allowed by law (Virginia Statute 54.1-2969) (Md. Code Ann., Health-Gen. II § 20-102). Please be aware that for any lab work minors must be accompanied by their parent or legal guardian.
B. Your children are our top priority. So that we may continue to provide each child with the best care possible, we expect that all parties involved communicate regarding all aspects of the child’s healthcare. Unless legally restricted, we cannot deny access to either parent regarding patient care or information.
C. We depend upon the adult present with the child in the office to convey any information to all parents or legal guardians in need of that information.
D. If we are contacted by another parent or legal guardian after the visit, we will certainly make every attempt to contact that parent or legal guardian and answer their questions unless we are prohibited from doing so by court order. Given that such communication may take almost as much time as the original appointment, it may increase the charge for the appointment or may incur a separate, additional charge that may not be covered by insurance.

PRIVACY PRACTICES
A. By signing below, you authorize the release of any medical or other information necessary to process claims related to general dermatology (medical) services received by yourself or your dependent. You assign all medical payment on your behalf or that of your dependent for services provided to be issued to McLean Dermatology and Skincare Center, PLLC, 6849 Old Dominion Dr., Suite 450, McLean, VA 22101; or issued to Potomac Dermatology and Skincare Center, PLLC, 9812 Falls Road, Suite 124, Potomac, MD 20854.
B. We are required by law to provide you with a copy of our Notice of Privacy Practices and our Office Policy.

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At McLean and Potomac Dermatology and Skincare Center, we are committed to providing the best dermatologic care.

This agreement must be signed in order to be seen by providers at McLean and Potomac Dermatology and Skincare Center.

INSURANCE POLICIES
A. Your insurance policy is a contract between you and your insurance company. It is essential that you understand which services and procedures are covered by your insurance plan and obtain any necessary authorizations or referrals prior to your appointment with us. Any questions regarding participation or coverage should be directed to your insurance company.
B. We accept plans through the following payers as in-network providers:  Aetna, Anthem BCBS, Federal BCBS, Carefirst Blue Choice, Cigna, United Healthcare, GEHA, UMR, Medicare.
C. We will bill participating insurance companies as a courtesy. Guarantor is responsible for all charges processed by their insurance company that are determined to be non-covered services, deductible, coinsurance and/or co-payments.
D. It is the responsibility of the guarantor to notify our office of changes in insurance and/or demographics in a timely manner. Failure to notify the office of changes may results in claims being denied for timely filing, and unpaid charges will be billed as the patient/guarantor responsibility. Unless otherwise directly, the guarantor will be the insurance policy holder.
E. We cannot guarantee that we accept your specific plan as an in-network provider; it is your responsibility to verify your insurance benefits and coverage prior to your visits.
F. We will not submit claims to any other insurance company other than those listed above. If you have a secondary insurance in addition to one of the plans listed above, we will file a claim to your secondary insurance as an out-of- network provider. In such instances, we cannot guarantee complete coverage.
G. If we do not accept your insurance, the charges for all services are due in full at the time of service. All sales are final.
H. General dermatology services will be processed through the insurance on file or payment is due at time of service by the patient – if no insurance is on file.
I. WE ARE CERTIFIED WITH TRICARE, BUT WE ARE NOT CREDENTIALED (IN-NETWORK). WE WILL BE ABLE TO FILE YOUR VISIT WITH TRICARE, HOWEVER, THERE WILL BE A BALANCE REMAINING BEYOND TRICARE’S COVERAGE THAT YOU WILL BE RESPONSIBLE FOR.
J. Please note: several United Student Resources plans do not cover hair loss visits; verify your coverage and benefits prior to your visit so you are aware of your plan benefits and limits.
K. We are not contracted with Medicaid, or Medicaid Replacement Plans, and CANNOT see patients that have Medicaid or Medicaid Replacement Plans unless you agree to be Self-pay. If you have Medicaid, or Medicaid Replacement Plan, or plan to apply for either, you will need to find a provider that accepts Medicaid insurance.
L. It is your responsibility as the patient to understand your insurance plan limits and restrictions that affect coverage of services you receive.
M. Calls returned by a provider for patient evaluation/advice may be billed to your insurance based on the time required for the call and documentation. Depending on your insurance coverage, you may be responsible for charges for a Telehealth visit.
N. Please do not ignore patient billing statements. If you receive a billing statement from our office, charges have been submitted to, and have been processed by, your insurance company. Although our business office is available to answer any questions you may have, we ask that you please message our billing manager with questions regarding co-pays, co-insurance, deductibles and/or coverage.
O. Patient account balances more than 90 days past due will be required to arrange for payment prior to scheduling an appointment. Past due accounts may also be turned over to our collection agency and the patient may be dismissed from the practice.

P. Medicare patients are responsible for any balances due for services that are not covered by Medicare.

 LABORATORY BILLING

A. For your convenience, we offer blood draws and urine pregnancy tests on premises. Both in-office services will be billed through insurance. Urine pregnancy tests are completed entirely in office. Blood draws will be sent to an off-site laboratory for processing, which may result in additional billing through their office.
B. If your insurance company requires you to use a specific laboratory in order for laboratory fees to be covered, it is your responsibility to request this.
C. If you have biopsy or any lab testing in our office, you and/or your insurance will be billed for the corresponding lab charges. The lab is a third party and will bill you for remaining balances. THE THIRD PARTY LAB FOR PATHOLOGY IS FAIRVIEW LAB IN MINNESOTA. OUR OTHER THIRD PARTY FACILITY FOR ALL OF OUR LAB TESTING IS LabCorp. 
D. All Lab work or Pathology are filed with your insurance. Should you receive a bill from Labcorp, Quest Diagnostics, Dermatopathology (Dermpath Diagnostics) or Fairview please contact their billing department. Should you have questions or need additional information, please ask one of our staff members for assistance.

LabCorp Billing Customer Service: 1-800-845-6167 

Quest Diagnostics Billing Customer Service: 1-866-697-8378

Dermatopathology Billing Customer Service: 1-866-625-3309

Fairview Pathology in Minnesota Customer Service: 612-672-6724

24-HOUR CANCELLATION POLICY
A. You will be billed a $50 “Cancellation/No Show Fee” for each appointment cancelled/rescheduled or missed, without 24-hour notice for MONDAY-FRIDAY APPOINTMENTS.
B. You will be billed a $100 “Cancellation/No Show Fee” for each appointment cancelled/rescheduled or missed, without 24-hour notice for SATURDAY APPOINTMENTS.
C. You will be billed a $150 “Cancellation/No Show Fee” for all procedure appointments cancelled/rescheduled or missed, without 24-hour notice (Excisions, surgeries, etc.) ANY DAY OF THE WEEK.

COLLECTIONS AND FEES
A. In the event that your account is put into collections, the balance must be paid in full – in order to schedule any future office appointments or even request prescription refills.
B. Past due balances more than 90 days with no payment activity, will be assessed a monthly $25.00 late fee. Past due balances of $500.00 or more will also incur 6% interest.
C.Credit card payments may be subject to additional processing fees at the point-of-sale.

PRIVACY PRACTICES
By signing below, you authorize the release of any medical or other information necessary to process claims related to general dermatology (medical) services received by yourself or your dependent. You assign all medical payment on your behalf or that of your dependent for services provided to be issued to McLean Dermatology and Skincare Center, PLLS, 6849 Old Dominion Dr., Suite 450, McLean, VA 22101, or issued to Potomac Dermatology and Skincare Center, PLLC, 9812 Falls Road, Suite 124, Potomac, MD 20854

We are required by law to provide you with a copy of our Financial Agreement and our Notice of Privacy Practices.

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To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Lily Talakoub, M.D. (Business Owner). For our McLean location contact 6849 Old Dominion Drive, Suite 450, McLean, VA 22101 or call 703-356-5111. For our Potomac location 9812 Falls Road, Suite 124, Potomac, MD 20854 or call 703-356-5111.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Lily Talakoub, M.D. (Business Owner).  

We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from our office. We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses

Directory
[Only for hospitals.] Unless you notify us that you object, we will use and disclose your name, location, general condition, and religious affiliation in a hospital directory. This information may be provided to members of clergy and, except for religious affiliation, to other people who ask for you by name.

Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Research
We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Disaster Relief
We may use and disclose your protected health information to assist in disaster relief efforts.

Organ Procurement Organizations
Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Public Health
As authorized by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability; to report reactions to medications or problems with products; to notify people of recalls; to notify a person who may have been exposed to a disease or who is at risk for contracting or spreading a disease or condition.

Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Employers
We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution or its agents the protected health information necessary for your health and the health and safety of other individuals.

Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.

Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.
Serious Threat
To avert a serious threat to health or safety, we may disclose your protected health information consistent with applicable law to prevent or lessen a serious, imminent threat to the health or safety of a person or the public.

For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Coroners, Medical Examiners, and Funeral Directors
We may release health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release health information about patients of Covered Entities to funeral directors as necessary for them to carry out their duties.

Other Uses
Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under "Your Health Information Rights”

Website
If we maintain a website that provides information about our entity, this Notice will be on the website.

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