Authorization, Consent of Professional Services and Release of Information:
I hereby authorize Pacific Skin Institute to provide insurance companies or their representatives information concerning my (or my dependents) illness and treatments and I hereby assign to Pacific Skin Institute, PC all payments for medical services rendered by myself or my dependents. Necessary forms will be completed to expedite carrier payments, however the balance of any uncovered services are charged to the patient . All copays, deductibles and known uncovered services/treatment provided to you as a patient of Pacific Skin Institute are payable at the time of service and are the sole responsibility of you “the patient” and/or guarantor of “your children”. I understand that I am responsible for any amount not covered by insurance .
I hereby authorize and release the Medical Provider and whomever he/she may designate as an assistant to administer treatment, physical exam, imaging, laboratory procedures, or any medical service that he/she deems necessary in my case, and I further authorize him/her to disclose all or part of my patient record to any person/corporation which may be liable under contract to the clinic, the patient, a family member or employer of the patient, including but not limited to hospital or Medical Services Company, Insurance Company, Welfare Funds, or the patient's employer.
I understand that Pacific Skin Institute, as a comprehensive Skin Care/Dermatology Practice, believes in the value of cutting edge Clinical Research and advancing medical education. I understand that clinical trials are available to me outside of my medical care and insurance coverage through Integrated Skin Science Research (ISSR). I understand that as a premier center for advancing medical education, on occasion, Medical and Physician Assistant students and residents may be involved in my medical care team.
Patient Information Consent: I understand that Pacific Skin Institute may need to use and disclose information about my health or medical problems for the purpose of arranging, conducting, or referring my treatment, for obtaining payment, and for the purpose of operating the Practice. I consent to the use of my information for the purpose of treatment, payment and healthcare operations.
I understand that my consent is not needed if the law requires Pacific Skin Institute to report some aspect of my protected health information to a Government Agency (I.E. suspected abuse, communicable disease and potential bodily harm to myself or others).
I understand that I have the right to review Pacific Skin Institute’s Privacy notice, to request restrictions be put on the use of my information, and to revoke my consent at a later date. I understand that if I withhold consent for the use of my information for the purpose of treatment, payment or operation, Pacific Skin Institute may refuse to undertake my care.
I hereby consent to the following: Administration and performance of such procedures as may be deemed necessary or advisable in the treatment of this patient, administration of any needed anesthetics, use of prescribed medication, performance of diagnostic procedures/tests, cultures, biopsies and surgery, performance of other medically necessary and accepted laboratory tests that may be advisable based on the judgement of the attending physician or their assigned designee. I intend this consent to be continuing in nature even after a specific diagnosis and treatment recommendations. The consent will remain in full force until revoked in writing. I understand that Pacific Skin Institute may include consent at satellite offices under common ownership.
I authorize the release of my medical information about me to the Social Security Administrators or its intermediaries for my medical claims. I assign the benefits payable for services to Pacific Skin Institute.
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its content. I certify that all of the information provided above is true and correct to the best of my knowledge.