New Patient Intake Packet (Online Form)

Parent or Responsible Party

Financial Policy

Thank you for choosing Sanova Dermatology! We are committed to the success of your medical treatment and care.

Please understand that payment of your bill is part of this treatment and care. We strive to take part in a large number of insurance plans in order to offer our patients more choices for reimbursement of the care we provide. As a service to you, we work to file, process, and collect your insurance claims in as timely a manner as possible. Your active involvement and understanding in this process will assist us in this mission. Please review the following:

Please read each paragraph of our financial policy and sign at the bottom of this page

Insurance-Claims. If we participate with your managed care or commercial insurance plan under which you are covered, we will bill the carrier for all charges for services rendered. We will bill both your primary and secondary insurance plans. You will be responsible at the time of service for the payment of:

• The copayments and annual deductibles

• Charges for non-covered or cosmetic services

  We will call your insurance company to verify eligibility and benefits. However, verification of benefits is not a guarantee of payment. You will be billed a balance if:

• Your insurance company pays less than what we expected

• We obtain a denial from your insurance company

• Insurance companies consider any treatment or procedure that is not part of the history, physical exam or writing a prescription to be a surgery. Essentially, any physical treatment of a skin condition (including but not limited to: cutting, freezing, burning, lasering, applying chemical, caustic or blistering agents, curettage, draining or lancing, removal of a foreign body, injections, application of light therapy, scraping) is considered a surgical treatment by insurance companies.

• We have not received payment from the insurance within 60 days of our filing the claim

  Please be advised that anything you choose to have removed, biopsied, or injected may not be covered under your office co-pay and might be excluded from coverage or subject to your deductible. We will make every effort to contact your insurance company to verify your benefits, but in the event we are unable to reach them, you will be responsible at the time of service for your co-payment as well as payment for procedures performed. Such procedures include but are not limited to biopsies, injections, removal of warts, moles, pre-cancers, skin cancers, or other skin lesions. Methods of removal may include but are not limited to: cutting, freezing, burning or application of a blistering agent.

  Authorization/Financial Responsibility. I authorize the release of any medical information necessary to process an insurance claim on my behalf. I understand that I am financially responsible for all charges and responsible for obtaining referrals required by my insurance carrier. I request that my medical insurance carrier make any payment directly to Sanova Dermatology, PLLC for services rendered to me.

  Medicare. We are Medicare participating providers, therefore we will bill Medicare directly. You will be responsible at the time of service for payment of:

• The copayments and annual deductibles

• Charges for non-covered or cosmetic services

You will be asked to sign a Waiver of Liability in the event a service is provided that is not covered by Medicare.

Patients without insurance coverage OR Out-of-Network coverage. Payment is due for all services on the day they are rendered.

Returned Checks. There will be a $25.00 service fee charged to your account if your check is returned for any reason. Upon notification from our office, payment of the entire balance is due immediately.

Skin Care products. If you purchase skin care products/supplies from our office, please understand that these items are non-refundable. If the product/supply is defective, we will gladly replace the item(s).

No Show Policy*. We kindly request that you give us 24-hour’s notice if you are unable to keep your appointment.

Failure to give 24-hour notice will result in a missed appointment fee. This fee is not covered by your insurance plan. Failure to give 24-hour notice for Cosmetic appointments may result in the loss of your deposit.

We understand that situations may arise that prevent adequate notice of cancellation. These situations will be considered on a case-by-case basis. If you have any questions, please do not hesitate to ask us. We are here to assist you any way possible. *Please see attached No Show Policy.

I have read and understand the Financial Policy for Sanova Dermatology and have reviewed the above listed notices. I understand my responsibility regarding charges incurred in this office.

No Show/Late Cancellation/ Deposit Policy

This policy has been established to help serve you better.

It is necessary for us to make appointments in order to see our patients as efficiently as possible. No-Shows and late cancellations cause problems that go beyond a financial impact on our practice. When an appointment is made, it takes an available time slot away from another patient. No-shows and late cancellations delay the delivery of health care to other patients, some of whom are quite ill. Due to limited availability and high demand of appointments, we would like to remind you of our scheduling policies.

A “No-Show” is missing a scheduled appointment. A “late cancellation” is cancelling an appointment without calling us 24 hours in advance for an office visit or 48 hours in advance for a procedure.

We understand that situations such as medical emergencies occasionally arise, in which case adequate notice for a cancellation is not possible. These situations will be considered on a case-by-case basis.

Medical Appointments:

• A $35.00 fee will be charged to your account for any changes or cancellations made to your appointment without a 24-hour notice.

All Appointments:

• A 15-minute grace period is allowed for patients running behind their scheduled time. Any patients arriving 15 minutes after their scheduled appointment time may be asked to reschedule their appointment. If you are running behind, please call our office and let a staff member know what time you plan to arrive.

A charge of $200.00 may be assessed for each no-show or late- cancellation for all surgery and/or cosmetic procedure appointments. A 48-hour notice must be given. We have set aside an extended amount of time for these types of appointments.

By scheduling your appointment and/or paying your deposit, you agree that you understand and accept these policies.

Please understand that insurance companies consider this charge to be entirely the patient's responsibility.

Secured Credit Card Policy

Poole Dermatology has a secure method through our Authorize.net/FirstData gateway connection to establish a secured credit card program to make our billing services more efficient and secure for all patients. Poole Dermatology will never maintain or document credit card numbers within the patient account, medical record, nor within our facility. This Credit Card policy agreement will only be referenced by the last four digits of the card.

Authorization for Secured Credit Card Payments

I understand that once my insurance company has reviewed the information with respect to my health care visit, Poole Dermatology and I will receive an Explanation of Benefits (EOB). Poole Dermatology's billing department will review the EOB for claims processing accuracy. In the event that we feel a claim has been denied in error or processed incorrectly, the insurance department will re-bill and/or appeal the claim as needed before any remaining patient balance is billed to my card on file. All correctly processed claims will state any balance to be paid by me for my health care visit. I agree that Poole Dermatology may charge my credit/debit, HSA card on file for any remaining balance due when they receive a copy of the EOB. Furthermore, if my card is expired or no longer valid, I agree to provide Poole Dermatology an updated credit/debit, HSA card. If there is a remaining balance due more than $250.00, you will receive a courtesy call prior to your card being charged at the phone number listed below. This Authorization form is in conjunction with any forms currently on-file with our office.

I authorize Poole Dermatology to charge the patient-responsible balances (e.g. co-pays, co-insurance, deductibles, non-covered services, elective items) on my account to the credit/debit, HSA card given below.

-This is a system everyone should be comfortable with— just like any hotel or rental car agency: All patients of Poole Dermatology will need to have a credit, debit or HSA card encrypted and securely stored. Once your insurance company has processed all charges and we receive their approval of exact patient responsibility, your card will be charged the remaining balance you owe, if any.

-Our system is vastly more secure than giving your credit card information over the phone or handing your card to a waiter in a restaurant: The card information is not available to our office staff, but is immediately encrypted and then securely stored with Authorize.net, our gateway provider.

-You remain in control: A receipt will be mailed to you along with a detailed explanation of services outlining the amount that your insurance has paid and the remaining balance that was owed for your dermatology visit. We will extend a courtesy call prior to charging the card on file if the charges exceed $250.00. We doubt there will be issues, but you remain in control by being able to decide/change which card is kept encrypted on file at any time.

-We appreciate your faith in us!: We are fortunate to have your trust in delivering health care to you, and we are confident that this policy will insure a safer and more efficient billing process for all, helping to keep health care cost down.

ATTENTION PATIENTS:

YOU MAY RECEIVE A BILL FROM AN OUTSIDE LABORATORY

At times, it may be necessary to have additional laboratory testing performed during your visit to assist in the diagnosis and proper treatment of a skin condition. If your provider performs a biopsy or other lab test during your appointment, it will be sent to an outside laboratory to be examined by a pathologist. The pathologist will communicate the test results to your provider via a pathology report.

The outside laboratory will submit a bill to your insurance company. You may receive a bill from them if you have deductibles, coinsurance, or copayments.

We are aware that insurance coverage varies by plan. If you know the preferred laboratory for your insurance carrier please advise our staff and we will make every effort to ensure that the specimen is sent to the correct laboratory. If you are unsure, please call your insurance company and ask if there is a preferred/In-Network laboratory.

If you’re a self-pay patient, rates will be discussed with you during your visit.

If you have any questions regarding this process, please do not hesitate to ask your physician during your exam.

By signing below, you understand that you may be billed by an outside laboratory in the event that you receive a biopsy or lab test during your examination.

FINANCIAL DISCLOSURE NOTICE TO PATIENTS

This is a notice informing you that Poole Dermatology, a Sanova Dermatology Company owns and operates Gulf South Pharmacy for the convenience of our patients.

As an owner, he/she will receive remuneration for securing or soliciting patients for prescriptions you have filled at this entity or any items or services you may purchase or receive.

As a patient you have the right to obtain these items or services from a pharmacy or provider of your choice. You always have a choice in pharmacies and are in no way obligated to use our pharmacy.

By signing below, you are acknowledging that you have received notice of the information provided above.