Patient Forms

Cancellation and No Show Policy

We understand that situations arise in which you must cancel your appointment.

It is therefore requested that if you must cancel your appointment, that you provide at least 24 hours’ notice.

Any appointments which are cancelled or rescheduled with less than 24 hours’ notice may be subject to a cancellation fee.

Patients who do not show up for their appointment without a call to cancel an appointment will be considered a “No Show”. These appointments may be subject to a No Show fee.

The fees are as followed:

• General Dermatology = $25.00,
• Cosmetic = $40.00,
• Surgery = $75.00.

The Cancellation and No Show fees are the sole responsibility of the patient and must be paid in full before the patient’s next scheduled appointment.

We understand that special, unavoidable circumstances may cause you to cancel within 24 hours. Fees in this instance may be waived but only with management approval.

Guarantor / Responsible Party Info

Additional Contact Information (someone NOT living in the same residence)

I request that payment of authorized insurance benefits be made either to me or on my behalf to Associates in Dermatology, Inc. (AID), for any services furnished to me by the listed provider/employee of AID. I authorize any holder of medical information about me to release to any federal or commercial health insurance organizations any information needed to determine these benefits or the benefits payable for related services.

I understand by signing this form that I am requesting that insurance payments for services rendered to me be made directly to AID and that I am authorizing the release of my medical information to pay applicable claim(s). If “Other Health Information” is indicated in item 9 of the HCFA 1500 form, or elsewhere on other approved claim forms, or electronically submitted claims, my signature authorizes the release of information to the insurer or agency shown. With certain insurers, the patient may be responsible only for the deductible, co-payment, co-insurance, or non-covered services. Co-insurance and the deductible are based upon the charge determination of the individual carrier.

I understand that if my insurance company requires a referral form for treatment that it is my responsibility to obtain this referral prior to my appointment. If the required referral form is not received, I understand that my appointment may need to be rescheduled until such time as the referral can be obtained.

The undersigned states that they have read the materials provided or had them read to them, and they understand payment is due when services are rendered. Upon default in making payment, the undersigned agrees to pay all reasonable legal fees and costs of collection to the extent permitted by Virginia law. Each guarantor waives presentation of payment, notice of non-payment, protest and notice of protest and agrees to all extensions, renewals, or release, discharge or exchange of any party or collateral without notice. This note shall take effect as a sealed instrument and be enforced in accordance with the laws of the Commonwealth of Virginia. This agreement shall be binding upon and inure to the benefit of the parties, their successors, heirs, assigns and personal representatives.

I have reviewed and accepted the Associates in Dermatology HIPPA Privacy Notice

I authorize Associates in Dermatology, Inc. to discuss my information with the following people:

Do you or any member of your family (parent, sibling, children) have a history of the following:

Have you had or do you have any of the following:

Telemedicine Informed Consent

Please read through this consent and check the acknowledgement at the bottom as your signature

I consent to engaging in telemedicine with Associates in Dermatology, Inc. I understand that telemedicine may include health evaluation, assessment, consultation, treatment planning, and therapy. Telemedicine will occur primarily through interactive audio, video, telephone and/or other audio/video communications.

Permissible telemedicine services available to me include prescription refills, appointment scheduling and patient education.

I understand that the provider is responsible for determining whether or not the condition or conditions being diagnosed during this telemedicine encounter is appropriate for this form of interaction/communication.

I understand I have the following rights with respect to telemedicine:

• I have the right to withhold or remove consent at any time without affecting my right to future care or treatment, nor endangering the loss or withdrawal of any program benefits to which I would otherwise be eligible.

• The laws that protect the confidentiality of my personal information also apply to telemedicine. As such, I understand that the information released by me during the course of my teleconference/consultation is generally confidential. Both mandatory and permissive exceptions to confidentiality exist including but not limited to legal proceedings where information is requested by a court of law. I also understand that the dissemination of any personally identifiable images or information from the telemedicine consultation to other entities shall not occur without my written consent,

• I understand that telemedicine-based services and care may not be as complete and in-person services. I understand that if my provider believes I would be better served by other interactions, that I will be referred to a provider who can provide those services in my area. I also understand that there are potential risks and benefits associated with any form of health treatment, and that despite my efforts and efforts of my provider, my condition may not improve, or may have the potential to get worse.

• I understand that I may benefit from telemedicine services, but that results cannot be guaranteed or assured. I understand that the use of Skype, Facetime, GoToMeeting, and Google audio/video systems are not 100% secure and may have issues with Wi-Fi connectivity. All attempts to keep information confidential while using these systems will be made but a guarantee of 100% confidentiality cannot be made with inherent issues with these communication systems. Signing this form reflects my awareness of these issues and a decision by me to use these systems for telemedicine services. To that end, I understand and agree that my provider and Associates in Dermatology, Inc. have taken reasonable security measures to protect my personal health information such as, by way of example but not by limitation, date of service encryption, password-protected screen savers, encrypted data files, and other reasonable and reliable authentication techniques. I will not hold Associates in Dermatology, Inc., or its staff liable for and thereby indemnify the provider and Associates in Dermatology, Inc., against gathering or use of client information by these service providers and against information lost due to technical failures.

• I understand that certain risks unique and specific to telemedicine, including but not limited to, the possibility that telemedicine consultations or other communications by my provider to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons.

• Payment Agreement/Assignment of Benefits: I agree to be responsible for any co-payments, deductibles, or other charges from Associates in Dermatology, Inc. that are not covered or paid by insurance or other third party payors except as prohibited by any state or federal law, or any agreement between my insurance company and Associates In Dermatology, Inc. I authorize Associates in Dermatology, Inc. to file any claims for payment of any portion of the patient bills, and assign all rights and benefits payable for health care services to Associates in Dermatology, Inc. I agree, subject to state and federal law, to pay all costs, attorney fees, expenses, delinquent charges, and interest in the event Associates in Dermatology, Inc. has to take action to collect the same because of my failure to pay all incurred charges in full. It is my responsibility to know what providers and telehealth services are covered under my insurance plan. I understand that I may be billed and agree to pay all bills submitted by Associates in Dermatology, Inc. in regard to the provision of telehealth services.

I understand I have the right to access my personal information. I have read and understand the information provided above. I expressly consent to the forwarding of information that identifies me as a patient to third parties. I have discussed these points with my provider, and all of my questions regarding the above matters have been answered to my approval.

By signing this document, I agree that certain situations specifically inclusive of emergencies are inappropriate for audio/video/computer based medical services. If I am in an emergency situation, I should immediately call 911 or go to the nearest hospital.