Patient Medical History

In case of an Emergency, who should be notified?

PLEASE PRESENT PHOTO ID & INSURANCE CARD AT TIME OF CHECK-IN

Insurance Subscriber Information (if different from patient):

I authorize River Region Dermatology & Laser to communicate PROTECTED HEALTH INFORMATION regarding me or my condition to the following individual:

All above information is correct to the best of my knowledge and I agree to notify this office in a timely manner of any changes.

Financial Responsibility
You are financially responsible for charges not covered by your insurance and for any charges that you do not want submitted to your insurance company. You are also responsible for payment of any deductible and co-payment determined by your contract with your insurance carrier. These payments are due at the time of service. If your insurance carrier denies any part of your claim, or if you and your physician elect to continue past your approved period, you will be responsible for your balance in full.

You are also responsible for any outstanding balances and must accept the fee charged as a legal  and lawful debt and agree to pay said fee, including any/all collection agency fees, (33.33%), attorney fees and/or court costs, if such be necessary.

You agree for River Region Dermatology & Laser and/or our agents to contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

Self-Pay Policy
If f you do not have health insurance, you will be responsible for services rendered by River Region Dermatology and Laser. The entire amount of the treatment given to the above-named patient will be due at each visit.

Routine Testing
I understand that routine testing may be needed to determine what treatment, counseling or referral may be required.

Appointment Policy

• Please arrive 10 minutes early for your initial visit to complete paperwork;
• Please call 24 hours in advance to cancel your appointment. Failure to do so will result in a $25 "No Show" fee. Monday appointments must be canceled by noon on the previous Friday.
• Please call to inform us any time that you will be late for an appointment. If you are running more than 15 minutes late, you may be asked to reschedule your appointment.

Healthcare Professionals
River Region Dermatology and Laser, PC supports training of healthcare professionals. I understand and agree to be interviewed, examined or counseled with a student present when receiving services.

Photography
I consent for medical photographs to be taken during my visit. 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. (Please indicating YES or NO below)

By signing this form below, I confirm that above information has been explained to me in terms which I understand.

In accordance with the American Medical Association Code of Ethics, our practice believes that the patient-physician relationship is based on trust and the confidentiality of communication. The free and uninhibited disclosures of personal information within this relationship are the cornerstone of good medical care. The privacy of your medical records is of the utmost importance to River Region Dermatology and Laser, PC. We have therefore taken measures to ensure that your medical records receive the highest level of confidentiality and security. This office adheres to the following procedures to ensure protection of your private medical records.

• Our office staff has received education and training regarding the use and handling of patients' protected health information (PHI)
• All patient paper records are secured in a locked facility during non-office hours
• Access to office keys are limited to the staff of this facility, building management and cleaning staff, who have all signed confidentiality agreements with our practice, and we have the ability to track access
• Access to electronic information is secured via passwords 
• Your private medical information is only released as required or permitted by state and federal law

In order to continue to provide personalized service to our patients and function effectively:

• We utilize outside services, such as transcriptionists or consultants
• Your name, status and location may be revealed within the office setting
• Laboratory, test results, and clinical notes may be shared with other physician(s) participating in your medical care
• Confidentiality can be expanded to exclude information issued to insurance companies by choosing to not use any health insurance or third-party payment as payment for services. In this scenario any and all health care services rendered, we will submit your charges to your health insurance, other third party, or employ the services of a collection agency
• If you request copies of your records, we will charge you per our states recommended fees
• Unless, you opt-out of participation, we will provide marketing materials to you that we deem appropriate for your care

I have received a copy of the River Region Dermatology and Laser PC Notice of Privacy Practices. My signature below confirms that I understand my rights and responsibilities.

I authorize the disclosure/request of the named individual's health information as described below. The following individual or organization is authorized to make the disclosure/request:

River Region Dermatology and Laser, PC 
2060 Berryhill Road
Montgomery, AL 36117 
(334) 676-3366

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire one year from date signed. I understand that I may contact the Privacy Officer at any time with questions about disclosures or to present my written revocation.

I understand that authorizing the disclosure/request of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure services/treatment. I understand that 1 may inspect or copy the information to be used or disclosed, as provided in 45 CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.