Financial Policy. Washington Square Dermatology Page 1

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Lucas Kevin Shaw
5 years ago
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1 Financial Policy Washington Square Dermatology is committed to providing patients with the best possible care and assistance. Our financial policy explains each aspect of the billing process within our office. In order to be seen in our practice, we require the following: Confirmation of insurance eligibility Co-payment paid in full Insurance Referral (if you have an HMO, POS or EPO insurance policy) o If your insurance plan requires a referral, it is your responsibility to obtain a valid one prior to your visit. o As a courtesy, if you do not have a valid referral for today s visit, you have the option of paying out of pocket, $150. A reimbursement will be refunded if your referral is received within the allowable billing period of your insurance company (usually days). All cosmetic services are payable at time of service. If you choose to not pay a co-pay or do not have a valid referral, we are happy to reschedule your appointment. Insurance Our office is contracted with many insurance companies. Each patient who is a member of an insurance plan that is contracted with our office will have their services submitted as a health insurance claim. If a patient has an insurance that our office is not contracted with, that patient would be considered self-pay and will pay the entirety of the visit at the time of service. Please contact our office to verify acceptance of your insurance plan. Qualifications for insurance coverage may differ between plans and individual procedures. Our office does not accept the following health insurance plans: Mass Health Medicaid Neighborhood Health Tufts Health Direct Boston Medical Center Health Plan United HealthCare Community Health Plan Billing Each patient who is a member of an insurance plan that is contracted with our office will have their services submitted as a health insurance claim. The patient will be responsible for any remaining balance not paid for by the insurance company. As a courtesy, we offer patients the ability to put a debit or credit care on file to cover any of the following balances. The agreement for the card on file will not exceed $1,500. Any overpayments made by either the patient or the insurance company will be processed and refunded with 60 days of receipt. Washington Square Dermatology Page 1

2 Reasons a bill may be generated Deductible The service you received is not covered by your insurance You have a copayment, coinsurance, or a deductible that has not been met or paid in full Your office visit copay has increased You received care outside of your provider network Your health insurance company limits coverage and you may have used all of your benefits for the year Some health insurance plans are organized by an annual deductible, which is decided upon by your insurance company. A deductible is a set dollar amount you must pay out of pocket during the year. After that dollar amount has been met, your insurance company will then begin to pay. For example, a health insurance plan may have a $1,000 annual deductible. The health insurance company will not begin to pay until the patient has met the $1,000 deductible. Please review your policy or contact your health insurance company for more information on your deductible. Coinsurance Coinsurance is a percentage of the health care bill that you pay. For example, you pay 20% and your insurance company pays 80%. Your out-of-pocket cost is based on the total amount that your insurance has allowed for the visit. It is your responsibility to understand your health insurance plan. Please contact your insurance company directly with any questions you may have about your coverage. Laboratory Services Some services performed in our practice such as biopsies, cultures and skin tag removals will be sent to a specimen laboratory for testing. You may receive a bill from either Informed Diagnostics Laboratory or Strata DX Laboratory. Please remember billing for specimen testing is not done through our office and if you may have any questions regarding the billing, please contact the laboratory directly. Authorization for Release of Information With my signature below, I authorize Washington Square Dermatology to release a comprehensive report related to patient care on services rendered including information such as diagnosis, clinical findings and treatment plans for the purpose of receiving payments for those services. This information may be released to authorized billing agents, insurance companies, employer s workers compensation insurance company, professional review organizations and other third party payers. This information will only be used on behalf of the patient. This authorization can be revoked at any time via written notice. Authorization for Assignment of Benefits In pursuit of payment for all medical services rendered, I authorize Washington Square Dermatology all rights and information needed in the interest of medical reimbursement with regulation under applicable state and federal laws. I understand it is my responsibility to provide Washington Square Dermatology with up to date and accurate information regarding my health insurance. Patient Name (Please Print) Patient Signature Date: / / Washington Square Dermatology Page 2

3 Receipt of Notice of Privacy Practices Written Acknowledgement Form I hereby acknowledge receipt of Washington Square Dermatology's Notice of Privacy Practices. Name [please print]: Signature: Date: OR I hereby acknowledge receipt of Washington Square Dermatology's Notice of Privacy Practices with respect to the patient. Name [please print]: Relationship to Patient: Parent Legal Guardian Signature: Date: Washington Square Dermatology Page 3

Personal and Insurance Information Last Name: First Name: MI: Date of Birth: / / Social Security Number: - - Sex: Male Female Marital Status: Single Married Divorced Widowed Street Address: City:

4 Personal and Insurance Information Last Name: First Name: MI: Date of Birth: / / Social Security Number: - - Sex: Male Female Marital Status: Single Married Divorced Widowed Street Address: City: State: Zip Code: Phone Numbers: ( ) - ( ) - ( ) - Home Work Mobile Address: Subscriber of Insurance (if not yourself): Subscriber s Social Security Number: - - Subscribers Date of Birth: / / Emergency Contact: Relation: Emergency Contact Phone Number: ( ) - I acknowledge and agree that I have received a copy of Washington Square Dermatology s Notice of Privacy Practices under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). Patient s Signature / / Date Washington Square Dermatology Page 4

5 PATIENT NAME: TODAY S DATE: / / DATE OF BIRTH: / / OCCUPATION: PREFERRED LANGUAGE: PREFERRED PHARMACY (NAME + PHONE NUMBER OR ADDRESS): PRIMARY CARE PROVIDER (FULL NAME AND PHONE/FAX NUMBER): RACE: White American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Decline to Specify ETHNIC GROUP: Hispanic or Latino Not Hispanic or Latino Unknown Decline to Specify Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplantation BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease PAST MEDICAL HISTORY (PLEASE CIRCLE ALL THAT APPLY): Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Other: Appendix (Appendectomy) Bladder (Cystectomy) Breast: Breast Biopsy Breast: Lumpectomy (Left/ Right/Bilateral) Breast: Mastectomy (Left/ Right/Bilateral) Colon (Colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Disease Colon: Colostomy Gallbladder (Cholecystectomy) Heart: Biological Valve Replacement Heart: Coronary Artery Bypass Surgery Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA PAST SURGICAL HISTORY (PLEASE CIRCLE ALL THAT APPLY): Joint Replacement: Hip (L/R/Both) Joint Replacement: Knee (L/R/Both) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Kidney: Nephrectomy Liver: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries (Oophorectomy): Endometriosis Ovaries (Oophorectomy): Ovarian Cancer Ovaries (Oophorectomy): Ovarian Cyst Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate (Prostatectomy): Prostate Biopsy Prostate (Prostatectomy): Prostate Cancer Prostate (Prostatectomy): TURP Rectum: APR Rectum: Low Anterior Resection Skin: Basal Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Spleen (Splenectomy) Testicles (Orchiectomy) Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Cancer Uterus (Hysterectomy): Cervical Cancer Other: OVER Washington Square Dermatology Page 5

6 Acne Actinic Keratosis Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin SKIN DISEASE HISTORY (PLEASE CIRCLE ALL THAT APPLY): Eczema Psoriasis Flaking or Itchy Scalp Rosacea Hay Fever/Allergies Squamous Cell Skin Cancer Melanoma Other: Poison Ivy Precancerous Moles DO YOU WEAR SUNSCREEN? YES NO IF YES, WHAT SPF? DO YOU TAN IN A TANNING SALON? YES NO DO YOU HAVE A FAMILY HISTORY OF MELANOMA? YES NO IF YES, WHICH RELATIVE(S)? DO YOU HAVE A FAMILY HISTORY OF OTHER SKIN CANCERS OR SKIN DISEASES? YES NO IF YES, PLEASE LIST WHICH RELATIVES AND DISEASES: CURRENT MEDICATIONS DOSE CONDITION/REASON FOR MEDICATION FREQUENCY DRUG ALLERGIES: SOCIAL HISTORY *Please only answer the questions you feel comfortable having in your permanent medical record. CIGARETTE SMOKING: Current every day smoker Current occasional smoker Former smoker Never smoker SEXUAL HISTORY: Not sexually active Sexually active with one partner Sexually active with more than one partner Same gender partner ALCOHOL USE: Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day SAFETY: I feel safe at home I do not feel safe at home ILLICIT DRUG USE: Drug use IV drug use Washington Square Dermatology Page 6

7 ALERTS (PLEASE CIRCLE ALL THAT APPLY): History of melanoma Allergy to latex Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past 2 years Blood thinners Defibrillator MRSA Pacemaker Premedication prior to procedures Rapid heartbeat with epinephrine Pregnancy or planning a pregnancy Faints with procedures West Africa: travel or contact Washington Square Dermatology Page 7

Patient Update Information

Patient Update Information Patient Name: Last First D.O.B If your info has not changed since your last visit, please sign the bottom of this page and all the consents for our yearly update! If any of the