Sapphire Dermatology Privacy Practices and Policies

Sapphire Dermatology Privacy Practices and Policies
Patient name*

First NameLast Name
Sex assigned at birth*

MaleFemale
Gender*
Date of birth*

MonthDayYear
Date
Parent/guardian name (if minor)

First NameLast Name
Authorization for Payment
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.
Patient Signature (or parent/guardian if minor)*

Clear
Date*

MonthDayYear
Date
Referral Information
How did you hear about us?*

Referring physicianGoogleYelpFacebook/instagramInsurance directoryFriend/family memberOther
Referring physician name, if applicable
HIPAA Consent
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.
Patient Signature (or parent/guardian if minor)*

Clear
Date*

MonthDayYear
Date
Appointment Cancellation Policy
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.
Patient Signature (or parent/guardian if minor)*

Clear
Date*

MonthDayYear
Date
Contact Information
Cell Phone Number*
Please enter a valid phone number.
Cell Phone Communication Consent*

Can leave a detailed voicemailCan leave a voicemail with call back number only
Home Phone Number
Please enter a valid phone number.
Home Phone Communication Consent

Can leave a detailed voicemailCan leave a voicemail with call back number only
Email (by providing an email address, you consent to receive our patient portal link and appointment reminders) *
Email Communication Consent (emails from info@sapphirederm.com are encrypted)

Can send a detailed messageDo not send a detailed message
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician*
Emergency Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Relationship*
Pharmacy Consent
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.
Consent to Receive Text Message, Email, and Phone Correspondence
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
By signing below, I have read and acknowledged this notice in its entirety.
Patient Signature (or parent/guardian if minor)*

Clear
Date*

MonthDayYear
Date
Please attach a copy or picture of the front side of your photo ID

Cancelof
Please attach a copy or picture of the front side of your insurance card

Cancelof
Please attach a copy or picture of the back side of your insurance card

Cancelof
Please attach a copy or picture of the front side of your pharmacy card (if applicable)

Cancelof
Please attach a copy or picture of the back side of your pharmacy card (if applicable)

Cancelof
Sapphire Dermatology

1860 Town Center Drive, Suite 350, Reston, VA 20190; (703) 215-9027

10801 Lockwood Drive, Suite 280, Silver Spring, MD 20901; (301) 244-9069
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Sapphire Dermatology Privacy Practices and Policies

Authorization for Payment

Referral Information

HIPAA Consent

Appointment Cancellation Policy

Contact Information

Emergency Contact Information

Pharmacy Consent

Consent to Receive Text Message, Email, and Phone Correspondence