TELEMEDICINE APPOINTMENT REQUEST

Important Information
Telemedicine visits are by invitation only and must be authorized by Lincoln Road Dermatology. Completion of this form does not automatically initiate a telemedicine visit. If approved, our office will contact you within 48 hours during regular business hours.

Fee and Insurance: A $225 fee will be charged upon completing this form, and photos must be uploaded. Insurance coverage for telemedicine is not guaranteed.

Refund Policy: Because telemedicine is not the primary way our office functions, the $225 fee will be charged at the end of this form. If and when your insurance reimburses for telemedicine services, we will issue a refund for the covered amount. If insurance is found to be inactive or denies the visit for any reason, you will be responsible for the full charge.

Note on Billing: This telemedicine option is our way of attempting to help patients who cannot come to the office. If you are uncomfortable with how we bill or collect information on this form, we welcome you to schedule an in-office visit to address your concern.

Questions If you have inquiries about telemedicine eligibility or diagnosis exclusions, call your insurance directly to verify, as our office will not be liable for any denials.

Note: Fields marked with a red asterisk (*) are required.

The success of this telemedicine consultation relies on your ability to provide multiple clear photographs and a detailed medical history. Similar to a traditional office visit, there is no guarantee of a cure or resolution after a single evaluation. For comprehensive care, in-office follow-up is strongly recommended.

Important Information:

Telemedicine and virtual consultations are not suitable for emergencies. If you are experiencing a medical emergency, call 911 or go to your nearest emergency room immediately.
This service is not appropriate for concerns such as skin cancer, multiple complex issues, or extensive conditions like hair loss, which typically require a more thorough in-office evaluation.
If you are unsure whether your concern is suitable for a telemedicine consultation, we recommend scheduling an in-office visit for a more comprehensive assessment.

Please note: All information in this form is for administrative input in anticipation of scheduling a medical visit or telemedicine visit. Any correspondence does not create a doctor patient relationship or initiate care of medical condition. Any communication via our website and/or email cannot replace the relationship you have with a physician. If you feel your situation is an emergency, please call 911 or go to the nearest emergency room.

INSURANCE POLICY/FINANCIAL POLICY/NO SHOW POLICY
I authorize Lincoln Road Dermatology (LRD) to submit claims and medical documentation if requested to my insurance of record for payment of insurance benefits to LRD. I understand it is my responsibility to obtain any referrals or prior authorizations in a timely manner and in the form necessary to satisfy my insurance contract. It is also my responsibility to verify with my insurance that LRD is “in network” or “out of network,” and I understand and agree to the way it affects my costs. Your insurance contract is between you and your insurance company. Any questions or clarification should be directed to your insurance company. I agree to update and provide LRD with an active insurance card and communicate in a timely fashion with my insurance should they need more information to process my claim. Any delays in this correspondence may lead to the entirety of the visit being my responsibility.

I understand I will be responsible for anticipated costs of services the day these services are rendered; however, total costs can only be determined after insurance reviews the claim. These costs include: any anticipated co-insurance, deductible, and/or copay, as well as any cosmetic costs. I understand LRD can make only good faith estimates of charges and that I am personally and fully responsible for any balances owed from previous dates of service, non-covered or denied services, including telemedicine, and late/no-show fees.

I understand LRD may refuse non-urgent services if I fail to make payment or payment arrangements on balances owed. I understand LRD reserves the right to charge a nonrefundable $50 fee for missed regular visits and a $75 fee for missed cosmetic, esthetic, or surgical visits. Missed appointments are due to failure to show or give >24 hours’ notice of cancellation from the anticipated appointment time. I understand this time was specifically reserved for my services and the time commitment was incurred by the office. Repeated no-show offenses may result in termination from the practice. Payment will be required to satisfy past due amounts prior to booking future appointments as well as a possible $50 or $75 hold for future appointments.

If a delinquent account is referred to a collection agency and/or attorney, I agree to pay the attorney's fees, court costs, and collection agency fees associated with the collection process.

MEDICARE PATIENTS
Medicare will send the claims automatically if your secondary is an automatic crossover. If your secondary fails to pay in a timely fashion, you are ultimately responsible for the costs (deductible and 20% copay). If no secondary crossover exists, you do not have secondary insurance, or we are out of network with your secondary insurance, you are responsible for your deductible and 20% copay at the time service is rendered. You will need to send your Medicare explanation of benefits to your secondary carrier. All payments owed after submission or adjudication will be applied to the credit card on file after an unanswered statement has been issued.

PROCEDURES / RISKS / LAB CHARGES
I understand that a procedure(s) may be necessary to help diagnose or aid in the management of my medical concern. Any procedure (biopsy, culture, surgery, injection or freezing, drainage, scraping, or cauterization) results in a procedure code or extra cost that is separate from the consultation, follow-up appointment, or visual evaluation of my skin concerns. I accept and understand the risks of a skin procedure, which may include but are not limited to: pain, bruising, bleeding, scarring, skin color changes, recurrence, infection, or the need for further medical or surgical management.

I consent and understand that tissue removed will be sent to an outside lab for evaluation and processing, which will result in additional billing or cost from the outside lab. This lab charge is independent and in addition to medical and/or procedural services done and billed by LRD.

CREDIT CARD ON FILE (CCOF)
I authorize Lincoln Road Dermatology and Marcy Alvarez DO, PA to keep my signature on file and to charge my credit card for the patient responsibility portion of any balances incurred, including deductibles, copays, or coinsurance applied by insurance, refusal by insurance to pay for services rendered, a bounced check or collections administration fee, a balance due to insurance cancellation, or fees associated with missed appointments.

Failure to show for an appointment or cancellation with less than 24 hours’ notice will result in a fee of $50 for a regular medical visit or $75 for a surgical, cosmetic, or esthetic visit. These charges will be processed within 24 hours of the missed appointment or billed to your account if the CCOF is not active.

REFUNDS
I understand that I am entitled to a refund should my insurance company later pay for services initially denied or pay for any portion of the claim initially considered patient responsibility. All refunds are issued to the original payment method or left as credit if unable to refund. Refunds are reviewed monthly, and insurance responses may take 2 weeks to 3+ months.

MEDICAL PHOTOGRAPHY
I authorize medical photographs to be taken of me, my child, or a person for whom I am the legal guardian by Lincoln Road Dermatology, its staff, or physician (collectively known as LRD). Photos are stored in our HIPAA-compliant electronic medical records system and may be used for medical records, treatment results, or third-party diagnostics and treatments. I give permission for LRD to transfer these photographs via email exclusively for third-party diagnostics, treatment, and continuing medical care (e.g., communication with my primary care physician or a referring physician).

TELEMEDICINE
I understand that telemedicine is the use of electronic communication technologies by LRD to deliver services remotely. I understand there are potential risks, including interruptions, unauthorized access, and technical difficulties. Telemedicine may not be appropriate for all skin concerns and could require an in-office evaluation or referral. If my insurance does not cover telemedicine services, I agree to pay the $225 fee in total for such services.

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (HIPAA)
By signing this form, I consent to the use and disclosure of my protected health information for treatment, payment, and healthcare operations as outlined in LRD’s Notice of Privacy Practices.

VOICEMAIL/TEXT/EMAIL CONSENT
I consent to LRD staff contacting me via phone, text, or email and leaving detailed messages as necessary, which may include personal or protected health information.

By signing below, I acknowledge that I have read, understand, and agree to all policies outlined above. 

If the patient is under the age of 18 or lacks capacity, I, the signing party affirms that I am either the parent or legal guardian of such patient and have full legal authority to seek medical assistance on behalf of the patient.