Sapphire Dermatology Privacy Practices and Policies

I request that payment of authorized medical benefits be made to Sapphire Dermatology on my behalf for any services furnished to me by this office. I authorize any holder of medical records to release to my insurance company(s) and its agents any information needed to determine those benefits payable for related services. I understand I am responsible for paying Sapphire Dermatology the deductible amount if it has not already been met. I further understand that I am responsible for the balance of my charges not paid by my insurance as contracted and allowed by my insurance company. I further understand that any deviation of the above agreement must be approved by Sapphire Dermatology Management.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent, I authorize the practice to use and disclose my protected health information (PHI) to carry out the following: Treatment (including direct and indirect treatment by other healthcare providers involved in my treatment); Obtaining payment form third party payers (e.g., my insurance company); Day-to-day healthcare operations. I have been informed of and given the right to review and secure a copy of the Privacy Statement, which contains a more complete description of the uses and disclosures of my PHI and my rights under HIPAA. I understand that the practice reserves the right to change the terms of the notice at any time and that I may contact the practice at any time to obtain the most current copy of this notice. I understand that I may revoke this consent at any time. However, any use of disclosure that occurred prior to the revocation date is not affected.

I understand that I will be charged a $50 fee if I do not call to cancel/reschedule an appointment within 24 hours of the scheduled appointment time.

I consent that Sapphire Dermatology may access my prescribed medications from my pharmacies. I may revoke this consent at any time by notifying Sapphire Dermatology. 

I consent that Sapphire Dermatology may send electronic communications for appointment confirmations and other routine business purposes, at any email address or phone number I provide. Messages may be sent by text, email, or automated phone messages. Message and data rates apply. I may opt out of receiving further automated, electronic communications at any time by calling 301-244-9069 or 703-215-9027 or emailing info@sapphirederm.com