New Patient Registration Forms

The following are internal policies set in place by CutisCo LLC d/b/a CutisCo Dermatology (“CutisCo”). Signature is required before services can be provided. CutisCo is unable to accept any revisions to this form and any attempted changes shall be null and void.

 

Assignment of Benefits

I hereby assign to CutisCo all my rights and claims for reimbursement under my health insurance policy. I agree to provide information as needed to establish my eligibility for such benefits.

 

Insurance Filing

If the clinician treating you is contracted with your insurance plan, we will furnish information required by the insurance plan to receive payment. If your insurance deems a service to be not covered by your insurance plan, you agree to be responsible for the balance of this service to the extent permitted by applicable law and insurance plan contracts. 

If the clinician treating you is not contracted with your insurance plan, we will bill your insurance plan for charges incurred at our clinic as a courtesy to you. Please remember that your health insurance is a contract between you and your insurance plan. We will furnish information required by the insurance plan to receive payment. Our office will make an attempt to settle any outstanding bill with your insurance plan. You agree to be responsible for the balance of the costs of the services provided to you that are not reimbursed by your insurance plan. Benefits should be paid directly to the Practice from your insurance plan. If your insurance plan reimburses you directly for any outstanding amounts due to us, payment will be expected by us within 10 days.

 

Co-payments, Co-insurance, Deductible, & Cosmetic Procedures

Payment is due on the date of service prior to seeing the clinician. Deductible amounts may be collected prior to the clinician completing the service. Payment for a cosmetic procedure is due in full prior to treatment. There are no returns on cosmetic products sold unless such products are defective or, in the opinion of your clinician, caused an adverse reaction. A $40.00 charge will be added for any non-sufficient funds notice from the bank. I understand and agree that I will be responsible for all legal fees and other costs of collection if my account is turned over to an attorney or agency for collection in which case your visit/s with our office may become a matter of public record.

 

Missed appointment & Late Cancellation Fees

We reserve appointment time specifically for you. To help us provide timely access to care for all patients, please notify us as early as possible if you are unable to keep your appointment.

Missed Appointment (No-Show): If you do not attend your scheduled appointment and do not provide advance notice, we may charge a $120 missed appointment fee.

Late Cancellation: If you cancel or reschedule your appointment with less than 48 hours’ notice, we may charge a $60 late cancellation fee.

These fees are the patient’s responsibility and are generally not billed to or covered by insurance. Additional scheduling restrictions may apply for repeated missed appointments or late cancellations.

 

Bad Debt Account Status

I realize that if my account is in bad debt, I am required to pay my outstanding balance prior to my scheduled appointment. I realize that if my account is sent to collections, CutisCo may also elect to dismiss me as a patient from the practice. If I pay off my bad debt account, my account will be returned to good standing status and I will not be required to make a deposit payment on future visits unless I am placed into collections again in the future. This provision does not apply to patients who currently have Medicaid health insurance coverage or to patients who are currently under bankruptcy or any other insolvency protection.

 

 

Non-insured Patients

Non-insured patients will be charged a deposit prior to seeing a clinician on the date of service. This is not considered payment in full. The deposit are determined by the individual clinic based on local considerations and will be at least as follows:

• New patient Office Visit: $300.00
• Established Patient Office Visit: $200.00
• Excision Visit: $800.00
• MOHS Visit: $1,000.00

 

Final charges will be determined after the clinician sees the patient and a complete assessment is made. The clinician may require payment in full for procedural services prior to rendering such a service and/or may require payment in full for all services on the date of the visit. If a credit balance is present on my account, the credit will be refunded to the payment form that was used to pay for the deposit.  

 

Open Payments Database Notice

The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov.

 

Procedure Pricing

I understand that procedure estimates are only provided in writing. Written estimates must be requested prior to the appointment unless otherwise required by law.

CutisCo may communicate with you regarding your care and account using the contact information you provide to us. Communications may include appointment reminders, scheduling information, pathology or laboratory results, responses to medical questions, billing and payment information, and other matters related to your healthcare or account.

At CutisCo’s discretion, confidential information may be left by voicemail or answering machine at the telephone number(s) you provide. We may also leave a message with a family member or other person who answers your telephone or is present at your residence when reasonably appropriate and permitted by law.

CutisCo may communicate with you by telephone, voicemail, email, SMS text message, mail, or other electronic means. You understand that certain methods of communication, including standard email and SMS text messaging, may not be encrypted and may carry privacy risks. CutisCo will handle protected health information in accordance with HIPAA and applicable state and federal law.

 

Calls, Text Messages & Electronic Communications

By providing your telephone number and contact information, you expressly consent to receive calls, text messages, and other electronic communications from or on behalf of CutisCo and its representatives. These communications may use automated technology or prerecorded messages and may relate to appointment reminders and scheduling, availability of pathology or laboratory results, billing and payment matters, collections, and other matters related to your care or account.

Where applicable, you may opt out of certain text communications at any time by replying STOP or using another available opt-out method. Your consent to receive automated calls or text messages is not a condition of receiving treatment or purchasing services from CutisCo.

 

Questions About Our Privacy Practices

If you have questions about our Notice of Privacy Practices or the use and disclosure of your health information, please contact our HIPAA Privacy Officer:

Phone: 888-321-7170
Email: privacy@cutisco.com

I hereby consent to the medical and surgical care and treatment, as may be deemed necessary or advisable in the judgment of my physician or other clinician. This may include, but is not limited to, laboratory procedures (including diagnostic testing such as lab draws and skin biopsies), medical and surgical treatment or procedure (including wart treatments, surgical removals, or excisions), or other services rendered during my visit with CutisCo Dermatology (“CutisCo”).

 

In order to ensure that you understand all aspects of your visit, you are encouraged to ask any questions or clarify any procedures prior to them being performed. Our dermatology clinicians will answer any questions and discuss any procedures, concerns and goals with you in regard to the following:

• Benefits of the proposed procedure.
• The way the treatment or procedure is to be performed.
• Alternative treatment options.
• Probable consequences of not receiving the treatment.
• The right to withdraw informed consent at any time, in writing.
• Risk and side effects involved with the procedure.
• Potential for additional incurred charges.

 

Should a biopsy be performed, or any other procedure in which a section of your skin is removed, the specimen will be sent to a pathology lab for an accurate diagnosis, unless otherwise recommended by your clinician. This process will involve any testing necessary including special staining or outside consultations which will incur additional charges.

With the automatic release of test results to your electronic medical record, it is possible that you will see results in your record before your physician or other clinician. Your treating clinician is trained to interpret your results based on your specific medical history and condition, and to reach a proper diagnosis and develop a proper treatment plan. I understand that, to avoid unnecessary concern, I am encouraged to speak with my clinician about any new concerning results.

 

I acknowledge that some medical diagnoses (such as warts) will require multiple treatments with one or more methods that may change throughout the course of treatment and each office visit and procedure will be billed accordingly.

 

With any procedure, there are risks involved which include, but are not limited to, the following:

• Scar – Scarring is possible with any procedure of the skin. We will do everything we can to provide you with the best cosmetic result possible, but the final cosmetic outcome is not guaranteed.
• Discoloration – pigment producing cells of the skin are sensitive and darkening or lightening of the skin may occur with any procedure.
• Infection – The entire procedure will be done in a sterile and/or clean fashion. Still, a small number of people will get a wound infection.
• Bleeding – Some procedure may create some bleeding. Rarely will someone have significant bleeding after they leave such that they would have to come back to have us treat it.
• Nerve damage – This will be discussed with you by your clinician if it is a known risk of your procedure.

 

CutisCo is committed to creating a safe environment for all patients and understands that the relationship between the clinician and the patient requires a high level of trust and professional responsibility. It also requires interactions that at times can involve sensitive physical examinations. To protect you and your clinician it is CutisCo’s policy that a chaperone or other third party be present for all sensitive medical examinations. The chaperone or third party is a member of our staff who serves as a reassuring presence for you and your clinician during your exam or procedure at no additional cost to you. I understand that I may opt out of having a chaperone or third party present for certain examinations or procedures and that the clinician may decline to examine or treat me at their discretion if a chaperone or third party is not present. I acknowledge that I can speak to a staff member or my clinician if I have questions or concerns.

 

Viruses: I recognize that CutisCo has implemented reasonable preventative measures aimed to reduce the spread of viruses. However, given the nature of viruses, I understand there is an inherent risk of becoming infected with a virus by virtue of proceeding with an elective treatment or procedure. I understand that possible exposure to a virus before/during/after my treatment or procedure may result in extended quarantine/self-isolation, additional tests, hospitalization and rehabilitation and the risk of other potential complications, including death. I hereby acknowledge the risk of becoming infected with a virus through this elective treatment or procedure.

 

I authorize pictures to be taken before, during and after the procedure. These pictures and digital images will become part of your medical record and may be used or disclosed as permitted by HIPAA. They may also be sent to your family physician and/or referring physician.

 

Since each insurance company has its own policies regarding the coverage of procedures, I also acknowledge that I am responsible for payment in full for the charges incurred for procedures regardless of the coverage provided by my insurance carrier. If I am concerned about the cost associated with treatment, it is my responsibility to request a procedure estimate prior to starting treatment.

 

I have read the consent form in its entirety. I understand the risks associated with procedures that may occur during my visits at CutisCo. I do not impose any limitations on CutisCo and its staff. I understand that I should discuss any questions or concerns with my dermatology clinician prior to any procedure and therefore, with my signature, agree to have any necessary procedures performed. I understand that if I would like to withdraw my consent at any time I will notify CutisCo in writing.

I certify that I have reviewed the information I provided in this registration form and that it is complete and accurate to the best of my knowledge.

I understand that I am responsible for notifying CutisCo Dermatology of any changes to this information.