I authorize medical photographs to be taken of me or my child or person for whom I am 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. I understand that the information may be used for my medical record and for third-party diagnostics and treatments. This includes photos for medical and cosmetic procedures to demonstrate before and after. I also give permission for LRD to transfer these photographs via email exclusively for the purposes of third-party diagnostics, treatment and continuing medical care (e.g. communication with my primary care physician, referring physician or self-appointed continuing care physician).
INSURANCE POLICY/FINANCIAL POLICY/NO SHOW POLICY
I authorize 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 the way it affects my costs. 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.
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 understand that I am personally and fully responsible for any balances owed from a previous date of service, non-covered or denied services, including telemedicine. This also includes cosmetic services or penalty fees for no shows/ bad debt.
I understand LRD may refuse nonurgent services if I am failing to make payment or payment arrangements on balances owed. I understand LRD reserves the right to charge a nonrefundable $50 fee for failure to show or give >24 hour notice of cancellation from your anticipated appointment time. I understand this time was specifically reserved for my services. Repeated offenses may result in termination from the practice.
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, scraped or cauterized) results in a procedure code or extra cost that is separate from the consultation or visual evaluation of my skin concern. I accept and understand the risks of a skin procedure may include but are not limited to: pain, bruising, bleeding, scarring, skin color changes, recurrence, infection or 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.
During the pandemic, the use of telemedicine may be utilized in my care. I understand that telemedicine is the use of electronic information and communication technologies by LRD to deliver services to me from a different location or site than I am. The visit may take place with the use of email, through a two-way video link-up or via telephone after submission of digital images. I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, delay in care and call termination and understand there are alternatives and limitations to this type of care. I understand the nature of my skin condition may not be suitable for telemedicine and could require in office evaluation, referral to another physician or evaluation at a hospital may be warranted in order to diagnose or treat. Therefore, termination of care may occur if telemedicine is deemed inadequate for the treatment and/or evaluation of your skin concern.
MEDICAL CARE DURING COVID-19
I understand that I am opting for evaluation, treatment, procedure, and/or surgery that is not urgent and may not be medically necessary. I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that Dr. Marcy Alvarez and all the staff at Lincoln Road Dermatology are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID- 19 by virtue of proceeding with any elective treatment, procedure, and/or surgery or in office medical visit. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment, procedure, visit and/or surgery, and I give my express permission for Dr. Marcy Alvarez and all the staff at Lincoln Road Dermatology to proceed with the same. I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test.
I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this elective treatment, procedure, visit and/or surgery can lead to a higher chance of complication and death. I understand that possible exposure to COVID-19 before/during/after my treatment, procedure, visit and/or surgery, may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment, procedure, and/or surgery, I may need additional care that may require me to go to an emergency room or a hospital.
I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the medical visit, elective treatment, procedure, and/or surgery itself. I have been given the option to defer my elective treatment, procedure, and/or surgery to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired elective treatment, procedure, and/or surgery.
I agree to abide by the masking at all time rule unless asked to remove my mask by the provider for treatment or evaluation purposes. This includes times where I may in the waiting room or examination room alone.
I understand that I am to come alone to my visit unless patient is accompanied by a single parent or legal guardian. This includes no guests in our waiting room. This is for the safety of elderly and patient who may be on immunosuppresant agents as well as our staff.
I undertsand refusal to wear a mask or maintain proper positioning of mask may result in termination of the visit and will incur any costs up to that point of service or incur a minimim $50 fee for the time alotted for your appointment (akin to no show fee for time held).
PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION (HIPAA)
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. Lincoln Road Dermatology provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting the office or viewing it on our website.
You have the right to request restrictions on how your protected health information is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement..
By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment from your insurance or other third party payors, and health care operations. You have the right to revoke this Consent, in writing, signed by you. Such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent.
I understand that:
• Protected health information may be disclosed or used for treatment, payment, or health care operations.
• I understand that the laws that protect privacy and the confidentiality of medical information including (HIPAA) also apply to telemedicine.
• LRD has a Notice of Privacy Practices and I have had an opportunity to review this Notice.
• LRD reserves the right to change the Notice of Privacy Practices at any time.
• I understand that I have the right to restrict the use of my information but the Practice does not have to agree to those restrictions.
• I may revoke this Consent in writing at any time and all future disclosures will then cease.
•The practice may condition treatment upon the execution of this Consent
Informed Patient Consent:
• I give my permission to LRD and staff to treat me, including any biopsy or procedures, use of outside laboratories for processing of tissue or fluid, and use of telemedicine services as deemed necessary within their professional judgment.
• I authorize LRD to take photographs for the clinical record.
• I understand the photographs obtained are the sole property of LRD and may include appropriate portions of the body to demonstrate the surgery/procedure. Every effort will be made to protect the patient’s identity in those materials.
•I also authorize the release of my medical records to third-party payors including Medicare and Medicaid.
VOICEMAIL/ TEXT/ EMAIL CONSENT FORM:
LRD staff may contact you via phone, text, email, and leave a voicemail on your answering service on any phone number associated with your patient profile. With your permission, we may leave detailed information including personal & protected health information on this voicemail.
I consent to allowing Lincoln Road Dermatology staff to leave detailed messages on answering machines, text or emails associated with any number/email on my patient profile. This includes but is not limited to demographic information (full name, date of birth, address, etc), appointment details, billing information (including insurance specifics or outstanding balances), medical information (including diagnoses, biopsy results, laboratory results, medication specifics, etc) or instructions from your physician.
I understand that this consent is not required to receive treatment at LRD and can be revoked at any time by sending a written request to Lincoln Road Dermatology, 1111 Lincoln Road #375, Miami Beach, FL 33139. Otherwise, this consent is valid until a revocation is requested.
By signing below, I understand and consent to LRD leaving detailed voicemails and emails which may contain personal details or protected health information.
If the patient is under the age of 18 or lacks capacity, I, the signing party, affirm 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.
If you have any questions regarding this notice, please contact the Office at email@example.com.