Patient Release: MUST BE SIGNED BY PATIENT OR IF PATIENT IS A MINOR, THE LEGAL GUARDIAN certify that the information that I have provided is correct. I authorize the release of medical information necessary to process insurance claims to insurance companies or their agencies (including Medicare) for purpose of filing and payment of medical claims. I authorize payment of medical benefits to the provider. I understand I am responsible for co-insurances, copayments and deductibles. If I am not insured or Reve Dermatology does not participate in my plan I am responsible for payment in full at the time of service

I certify that I hereby authorize Reve Dermatology , its providers and staff to provide my minor child in my absence with examinations and basic treatments following the initial visit for which additional consents are not required I understand additional written consent may be necessary for these types of procedures and that the legal guardian must be present for such consent.

Our goal is to provide you and your family with the best care in a warm, supportive environment. We wish to provide you with information that helps us to maintain this goal and through our Patient Policies. These Policies manage expectations and assure understandings to develop a long-lasting relationship. We remain available for any questions you may have.

Appointment Cancellations and No Shows
I understand late cancellation or missing an appointment prevents other patients from being seen and will provide at least 24-hours business notice for the need to cancel/ reschedule medical appointments and 48-hours notice for surgical and cosmetic visits.
I understand failure to give this notice will result in a $100 charge for missed medical appointments, $300 for missed surgical appointments and forfeiting of my cosmetic deposit or a treatment in my laser package.
I understand failure to give proper cancellation notice will result in a deposit being required for future visits in the amount of $100 for medical and $300 for surgical appointments. These deposits may be placed towards co-payments, balances or refunded once the visit is complete. These charges cannot be billed to my insurance company.

Late Arrivals for Appointments
I understand Reve Dermatology will do its best to accommodate me should I arrive late for an appointment. I understand “arriving late” means I have forfeited my appointment time and will need to wait to be worked back into the schedule when possible or be placed with another provider who may have availability. I also understand that there may be times when this accommodation is not available, and I will need to reschedule my visit.

Co-Payments, Deductibles and Co-insurances - Balances and Collections
Copayments are due and collected at check in on the day of the appointment. There is a $25.00 administrative billing fee for each co-payment that is not paid at the time of service. Insurance Deductibles, including Medicare, will be verified prior to the visit. All unmet deductibles may be collected at the time of service. Medicare patients without secondary insurance will be charged their 20% co-insurance at the time of service.

Balances and Collections
All balances are due in full within 30 days of my first billing. Any balance left unpaid after 60 days without attempt at resolution will be considered for collections. Should my account be sent to collections, I understand an additional 15% administrative collection fee plus any attorney / court fees may be added to my account during efforts to obtain payment. I am responsible for any bank fees associated with returned check fees plus a $35.00 administrative processing fee. Any returned check must be paid in full via credit card or cash within 10 days of notice or legal efforts to collect balance will be instituted.

Referrals It is my responsibility to know if my insurance plan requires a referral to see a specialist and to obtain referrals, track usage, obtain additional referrals as needed and verify Reve Dermatology has these referrals in their office prior to my visit.
I understand that if I do not verify a referral is in place for my visit and I am seen by the provider, I am considered a “Self Pay” patient and am responsible for all charges. My insurance company will not reimburse me.
If I do not have a referral and choose to reschedule the visit the same day, cancellation policies apply as outlined above. I understand I may not contact my Primary care provider to obtain a referral while at my appointment as it will not allow enough time to maintain my scheduled appointment and doing so will forfeit my scheduled time at Reve Dermatology .

Insurance Policies and covered benefits I will confirm my insurance is current at each visit. If there is a change to my insurance, I will provide a valid insurance card or temporary print out at the time of my visit or will be responsible for all charges. If the insurance information I present at the time of my visit is not correct, I will be responsible for all charges incurred.
If I am unable to produce an insurance card at my visit, I will either need to reschedule my appointment or pay in full at the time of service for my visit. Should I wish to reschedule my visit, the cancellation policies apply as outlined above. I will be responsible for submitting my receipts to my insurance company should I wish to be reimbursed for my visit.
My insurance carrier may consider certain routine services in dermatology to be surgical in nature or considered an uncovered benefit; and separate co-insurances, deductibles or co-payments or payments in full may apply. Each insurance plan is different, and I understand it is my responsibility to understand my policy and what will be covered.

Minor Patients
As a practice that often cares for children, we recognize the stress a family may encounter navigating the healthcare of the children under the best of circumstances. We also recognize this may be even more difficult in families where the parents are not together. We are here to provide treatment and support to you and your children, not to be incombered in the legal issues and responsibilities of the family.

I understand a legal guardian must sign all registration and consent forms for my child. If the legal guardian is not with the child at the visit, completed forms must be sent with the child along with the insurance cards. Full credit card information must be called into the office prior to the visit and remain on file. PARENT PRESENT FOR INITIAL VISIT

I understand that unless documents are provided showing otherwise, both parents are assumed to be authorized to schedule appointments and make treatment decisions for their child. Disagreements on approaches to treatment are between the parents to discuss.

I understand Payment (co-pays, deductibles, etc.) are due at the time of service regardless of which parent is responsible for medical coverage. Reve Dermatology is not a party to any divorce agreement. Payment is due from the parent who brings the child to the visit. If my divorce decree requires the other parent to pay all or part of the treatment costs, it is my responsibility to collect from the other parent.

I understand there may be times when I may allow my adolescent child to be unaccompanied for a follow-up visit and all payments that are due at the time of service will be handled by me either prior to the visit or with the credit card on file for my child. CHILDREN UNDER THE AGE OF 18 MUST BE ACCOMPANIED BY AN ADULT TO ALL FOLLOW UP VISITS

Insurance Inquiries:
It is my obligation to review any and all documents that are sent from my insurance plan. Occasionally, I will be required to update my insurance status with my insurance plan called a “Coordination of Benefits” Should I receive notification of this requirement, I will contact my insurance company within 5-days. I understand that my insurance claims will not be paid without my providing this information and I will be responsible for the entire balance.

Credit Card on File
We have implemented a policy requiring a credit card held on file for touchless transactions and convenience for all patients.

Your credit card will be swiped at check in and the information will be encrypted and held securely until your insurance has paid their portion. At that time, you will receive a call/ email that your credit card will be run for the balance as determined to be your responsibility by your insurance company.

I understand I will not receive a statement from Reve Dermatology and my EOB will be used to determine my financial responsibility.
This in no way will compromise my ability to dispute a charge or question my insurance company’s determination of payment. Additional information will be explained with our Credit Card on File policy form.

Cosmetic Deposits             250
A significant amount of time is reserved for our patient’s cosmetic appointments, and therefore a deposit of $200 is required for all cosmetic appointments at the time of scheduling. Other cosmetic services require a 50% deposit to schedule your appointment. Your deposit will be charged immediately and will be noted as a credit on your account. The deposit will be applied to the total charges on the day of your treatment. Cancellations/ reschedules with greater than 48-business-hours’ notice will be refunded or applied to the new appointment in full. Changes made with less than 48-business hours’ notice may forfeit the deposit in total.

COSMETIC CONSULT NEED TO COME UP W PRICING QUOTES VALID 60 DAYS USING CONSULT COST TOWARDS PROCEDURE 60 DAYS

HIPAA
Patients over the age of 18 are protected under the Federal Health Insurance Portability and Accountability Act. This Federal Law prohibits any staff member of Reve Dermatology from discussing appointments, medications, test results or treatment plans with anyone other than the patient.

Often, this causes difficulty for some patients who would like family members or caretakers to obtain information for them. This becomes especially important if your spouse or adult children assist with making appointments for you or if you are an adult college student away at school and your parents assist with prescriptions and appointments.

If you would like to permit someone to discuss your medical condition, confirm appointments, request prescriptions or obtain results for you, please indicate their name(s) below. You may edit this list at any time by speaking with our receptionist.

Please place a check mark next to the following methods we may use to contact you regarding your appointments and medical information and indicate below any persons authorized to speak with our office on your behalf.

I acknowledge and understand the above HIPAA policies and understand I may request a copy of the practice’s Notice of Privacy Practices related to the Health Insurance Portability and Accountability Act of 1996.

We are implementing a credit card on file process to streamline our payment processes, help minimize your hassle, and create better payment experiences. Similar to hotels and car rental agencies, you will be asked for a credit card at the time you check in.

The information will be held securely in an encrypted system; No one will be able to seeyour full credit card number, and it will be accessed by your name and Reve Dermatology account number.

Once your insurance company has processed your claim, you will receive an explanation of benefits (EOB) from your insurance company. This EOB will show what your insurance paid for and if you have any balance. Reve Dermatology will also be notified of this balance.

You will also receive an email from our office where you will have a choice to make a payment directly from the email or can allow the credit card on file to be used. You will not receive a statement in the mail. You will have 72 hours to decide, and any payment not made in 72 hours will be run for the balance. The 72-hour period provides you with an opportunity to call the office for questions, provide another method of payment, dispute the charges or request a payment plan before the card is run.

You will receive a receipt of the payment via email.
I understand I will not receive a separate statement in the mail from Reve Dermatology, but the email and EOB from my insurance company will outline all charges, payments and balances as determined by my insurance plan. I may use an HSA card; however an additional card is required to remain on file should funds not be available on my HSA card.

In signing below, I authorize and request Reve Dermatology to charge my credit card for balancesduefor services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me/ my child/ spouse for whom I provide this credit card.

This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 60-day notification to Reve Dermatology in writing and have no open or pending balances. I agree to provide an alternate card prior to the expiration date and will provide an alternate method of payment within 5 days should my card not contain enough credit/ monies to cover my balance. If my card declines for any reason, I understand I will be contacted by Reve Dermatology. I will have 5 days to provide payment and / or provide an alternate valid card. Should I fail to provide payment/ valid card in 5 days, I understand a $50.00 administrative fee will be added to my account.