3045 Southwestern Blvd. Suite 104 Orchard Park, NY

Transcription

1 ORCHARD PARK DERMATOLOGY Practice Information 3045 Southwestern Blvd. Suite 104 Orchard Park, NY Welcome to the office of Dr. Peter Accetta. Our practice is committed to providing you with the highest quality care, service and access. In order to help accomplish these goals, we would like to provide you with the following information. Office Hours Monday - Thursday 7:30 a.m. - 4:15 p.m. Friday - 0ffice is closed Phone Hours ( } Monday - Thursday. 8:00 a.m. to 5:00 p.m. Appointments Option 1 Billing Office Option 3 Monday - Thursday 8:00 a.m. - 4:00 p.m. A medical provider is on call seven (7) days a week to take urgent calls outside normal business hours. (Bleeding, Pain, Infection) For emergencies, call 911 Our phone message and website is updated as needed to report any closings; weather related, emergency or otherwise. Prescription Refills If you need a prescription refill, contact your pharmacy and the pharmacy will fax your request to us. You will receive a call only if there is a question or delay in filling your request Option 2 Form Completion A $25 fee is required to complete any forms. Please allow seven (7) business days for us to complete the forms. Test Results Please allow up to fifteen (15) business days for biopsy results. We will review test results as they become available and we will contact you with all results. Extension 212 Appointments Please arrive 15 minutes prior to your appointment time to register. For your benefit and the benefit of all our patients, we try to stay on schedule (though emergencies sometimes occur). As a courtesy, you will receive an automated pre-appointment reminder call 3 to 5 business days before your appointment. Please specify if you prefer to be reached by home phone, cell phone, text or . Let us know if you would like to be added to our cancellation list for a sooner appointment. BRING THE FOLLOWING ITEMS WITH YOU New patient forms printed from our website, filled out in full. Current INSURANCE CARDS, PHOTO ID and CREDIT CARD. Some insurance companies require a REFERRAL to see a dermatologist. Please contact your primary care physician to verify whether you need a referral. CO-PAYMENTS are required at the time of visit. There is a $50.00 additional fee if not paid at the time of the visit. If you arrive 15 minutes beyond your scheduled appointment time we may need to reschedule your appointment. Address and/or Phone Number Change It is important that the practice has your correct address and phone number on file. Please advise the practice anytime there is a change to your address, phone number, or other contact information. Participating Insurances The practice accepts most insurance plans, however, participation in insurance plans may change. It is your responsibility to verify that our providers are participating with your plan. It is also your responsibility to know which labs participate with your plan and advise us of any lab restrictions. We do not participate with Medicaid or any Medicaid product. Referrals and Pre-authorizations If the patient's insurance company requires a referral and/or preauthorization (for specialist visit), the patient is responsible for obtaining one for each visit Failure to obtain the referral and/or preauthorization may result in no payment from the insurance company and the balance will be the patient's responsibility. Medicaid, Workers' Compensation Our office does not participate with these plans, or any variation thereof. Revised 9/1/16

2 FINANCIAL POLICY Please refer to our website s Financial Policy tab for all your questions regarding our credit card on file policy. Explanations of common insurance terms can be viewed there as well. Co-pays and Deductibles All co-payments, deductibles, and past due balances are due at time of check-in. The practice accepts cash, check, or credit card. Insurance Claims The practice will bill the patient s primary insurance company as a courtesy. In order to properly bill the insurance company, the practice requires that the patient disclose all insurance information including primary and secondary insurance. Failure to provide complete and accurate insurance information may result in patient responsibility for the entire bill. It is the insurance company that makes the final determination of the patient s eligibility and benefits. The patient should verify that services are covered and that appropriate pre-authorization or referral is obtained when necessary. The patient is responsible for any non-covered services provided. If the insurance company is not contracted with the practice, the patient agrees to pay any portion of the charges not covered by insurance. We cannot bill insurance for cosmetic or non-covered services, therefore, full payment is required at the time of service. Your clear understanding of our Patient Financial Policy is important to our professional relationship. A detailed explanation can be viewed and printed from the Financial Policy tab on our website. Patients have the right to know what will be billed for procedures and may request anticipated costs. Outstanding Balance Policy We no longer send out billing statements. Your credit card on file will be automatically charged after your insurance company pays their portion. In the event that your balance goes unpaid, you will be subject to a $100 administrative fee, a collection fee of 33.3%, and all attorneys fees, related to the collection of the unpaid balance. Please refer to our credit card on file policy. Missed Appointments Our office requires 24 hour notice of appointment cancellations. Patients that miss appointments and do not cancel within 24 hour notice are charged a fee: $75.00 regular appointment and $ for cosmetic. Returned Checks Medical Records The charge for a returned check is $ Patients requesting copies of medical records are charged $.75 per page. DIRECTIONS TO ORCHARD PARK DERMATOLOGY LOCATED IN PARKLAND PROFESSIONAL PARK Access to our office from all points is most convenient via Countryside Lane. Turn right at the 1 st drive. Building 3045 is the 1 st building on the left, SUITE Reserve Rd. Michael Road North Berg Rd. 219 Orchard Park Rd. Lake Ave. Five Corners 240 Michael Rd. From Buffalo and points north Take NY State Thruway (90 West) to exit 55. Follow the signs to Orchard Park Route 219. Take 219 to Milestrip Rd. EAST. Proceed to the second traffic light and make a left on to U.S. Route 20 (Southwestern Blvd.). Go straight though the next light past the Tops/Lowes Plaza and make a right on Countryside Lane. From Springville, Ellicottville, Gowanda, Boston Take the 219 NORTH to the Milestrip Rd EAST exit. Make a left turn at the second light (Rt 20) which is Southwestern Blvd. Go straight through the next light past the Tops/Lowes plaza and make a right on Countryside Lane. 20 Union Rd. 20 Countryside Lane Tops Friendly Markets Milestrip Rd. 277 Lowe s 179 Angle Rd. To Tops / Lowes and Orchard Park Rd. Baker Rd Southwestern Blvd. Countryside Lane Southwestern Blvd. Rte. 20 Parking Lot Angle Rd. OUR LOCATION SUITE 104 Transit Rd. 187 From Westfield, Dunkirk, Fredonia, Silver Creek, Angola Take the NYS Thruway (90 East) to exit 56 (Milestrip Rd) and make a left turn at the light onto Milestrip Rd. Make a left turn at the 7 th signal (Rt 20). Go straight through the next signal past the Tops/Lowes plaza and make a right on Countryside Lane. From Cheektowaga, Depew, Lancaster, Elma, East Aurora Take Transit Rd (Rt. 78) SOUTH. Transit Rd leads into Southwestern Blvd. (Rt 20) WEST. Just past the signal at Michael Rd. you will make a left on Countryside Lane.

3 Patient Information (Please Print) 2016 Patient Registration Orchard Park Dermatology Peter Accetta, M.D Southwestern Blvd. Suite 104 Orchard Park, NY Please bring completed forms to our office Last Name First Name MI SSN Birth Date Age Sex M F Street Address City State Zip Home Phone - - Cell Phone - - Employer Employer Phone No. Primary Care Physician Name Phone No. - - Address Fax No. - - Preferred preference for appointment confirmation: Home Phone Cell Phone Cell Text Would you like to be contacted about special offers? Y N INSURANCE INFORMATION Primary Insurance (Insurance to be billed 1 st ) Insurance Carrier Patient ID No. Subscriber or person who holds policy information: Name Birthdate Relationship to Patient Subscriber ID No. Employer Secondary Insurance (Insurance to be billed 2 nd ) Insurance Carrier Patient ID No. Subscriber or person who holds policy information: Name Birthdate Relationship to Patient Subscriber ID No. Employer Signature Date Office Signature Date Office Signature Date Office Signature Date Office

4 2016 Patient Registration Orchard Park Dermatology Peter Accetta, M.D Southwestern Blvd. Suite 104 Orchard Park, NY Please bring completed forms to our office PATIENT PRIVACY INFORMATION (HIPPA) Please list any family members or other persons, if any, whom we may inform about your general medical condition and your diagnosis: Name and Relationship to Patient Name and Relationship to Patient Phone Number Phone Number Can messages be left on your home answering machine, voice mail or with a family member? Yes No Office Policies and Financial Agreements Please remember that insurance is considered a method of reimbursing the doctor and is not a substitute for payment. It is your responsibility to pay any co-pays, deductibles, co-insurance, and also any non-covered or denied services. PLEASE REMEMBER to bring your Insurance Card(s), Medicare Card, Drivers License, co-pay, and credit card. We expect full payment for co-payments at the time services are rendered. You are responsible for the entire balance on your account at the time service is rendered unless we have a special contractual relationship with your insurance company. Please discuss this with us in advance to avoid misunderstandings. You are responsible for cosmetic or non-covered services. Full payment must be made at time of service. In the event that your balance is unpaid, you may be subject to, and agree to pay: a $ administrative fee, a collection fee of 33.3% and all attorney fees, related to the collection of the unpaid balance. If you need to cancel an appointment, we request 24 hour notice. If you no show for an appointment there is a $75.00 fee for a regular visit, or a $ fee for a cosmetic visit. I understand that I am responsible for any and all referrals required by my insurance company. I authorize the release of medical information to my primary care or referring physician and as necessary to process insurance claims or prescriptions. I understand that I am responsible for presenting a copy of correct and current insurance information prior to, or at the time of service. If the insurance information presented is incorrect, I am responsible for all charges incurred at the time of service. I authorize payment of medical benefits be made to Dr. Peter Accetta for all services furnished to me. I understand that Orchard Park Dermatology, the office of Peter Accetta, M.D., may share my health information for treatment and billing. My signature constitutes my acknowledgement that I have been offered an opportunity to review the Notice of Privacy Practices from Orchard Park Dermatology containing a more complete description of the uses and disclosures of my health information. This signature states an understanding of the above information and authorization for our medical personnel to examine and treat this patient as well as authorizes release of medical information to the insurance company. I UNDERSTAND THAT THIS IS A LIFETIME SIGNATURE AUTHORIZATION. SIGNATURE: PRINT: DATE:

5 DERMATOLOGY MEDICAL HISTORY Patient: Date: / / What is your skin problem (growth, rash, etc.)? Please mark the location of your skin problem. When did your skin problem begin? Has a doctor given you anything for the skin (please list): Have you put anything on the skin yourself (please list): Are you allergic to any medications? YES NO If yes, please list: CURRENT OR PAST PROBLEMS WITH: (Review of systems) Check Yes or No, explain as necessary Yes No Please Explain: General Health Eyes Ears/Nose/Throat/Mouth Heart Lungs Stomach/bowel Kidneys Arthritis/muscles/joints Skin Headaches/seizures Psychological disorder Thyroid/diabetes Blood/bleeding disorder/hepatitis Allergic/immunologic SKIN PERTINENT PROBLEMS: Check any past or present skin conditions: Abnormal or Changing Moles Herpes Rash Acne Hives Malignant Melanoma Eczema Keloids Skin Cancer (Type: ) Excessive Scarring Previous X-Ray Treatments Other Frequent Sun Exposures Psoriasis For any checked boxes above, please explain when the condition appeared, what caused the condition (if known), and how the condition was (or is currently being) treated (if applicable).

6 Please list ALL other medications (prescription or over-the-counter) that you are now taking or have taken in the past 12 months: Note: If you are on more than 5 medications please attach an additional sheet. MEDICATION Strength How Often Check when Medication was STARTED: 0-3 months 4-6 months over 6 months ago 0-3 months 4-6 months over 6 months ago 0-3 months 4-6 months over 6 months ago 0-3 months 4-6 months over 6 months ago 0-3 months 4-6 months over 6 months ago FAMILY HISTORY: Check following conditions that have occurred in your family MOTHER FATHER BLOOD RELATIVE MOTHER FATHER BLOOD RELATIVE Allergies Heart Disease Arthritis High Blood Pressure Asthma Lung Disease Cancer Lupus Diabetes Malignant Melanoma Eczema Psoriasis Hayfever Skin Cancer SOCIAL HISTORY: Flu Vaccine YES (Date: ) NO (Why: ) Pneumovax YES NO Do you use tobacco YES NO Do you drink alcohol YES NO Drinks per week Do you have HIV (AIDS) YES NO (Women) Are you pregnant YES NO Due Date: / / What is your occupation? Hobbies? CONSENT FOR TREATMENT: I hereby consent to all surgical procedures and treatment, including, but not limited to, any laboratory and biologic test and administration of anesthetics, which are deemed appropriate and necessary for the treatment of the disorder about which I have consulted this office (I understand that this consent does NOT limit my right to refuse any treatment or procedure if I so choose). I am aware that a scar may result from any surgical procedure I may have, and that the type of scar cannot be determined before surgery. I further agree that the information listed on this form that I have provided is correct to the best of my knowledge. Completed by: Patient / / Signed by Patient Date Medical Assistant / / Initials Reviewed by Date Medical History Reviewed and Updated MA Initials Medical History Reviewed and Updated MA Initials Medical History Reviewed and Updated MA Initials Medical History Reviewed and Updated MA Initials Medical History Reviewed and Updated MA Initials PETER ACCETTA, M.D./SUSAN M. PETERSON, PA-C/EMILY GOTTSTEIN, PA-C/MARY CANNA, PA-C/CHELSEA SNYDER, PA-C ORCHARD PARK DERMATOLOGY CENTER ( ) 3045 Southwestern Boulevard-Suite 104-Orchard Park NY 14127

7 label Cosmetic Questionnaire At Orchard Park Dermatology Skin rejuvenation is about helping to restore your own appearance, not change it Check any area(s) of concern Forehead Frown lines Freckles & pigmentation Blood vessels Scarring Vertical lip lines (smoker lines) Large pores Poor skin texture & fine lines Crows feet Dark circles Nose to mouth lines Marionette lines Would you like to know more about.... Skin care Skin care products Mole removal Facial redness Spider leg veins Blotchy skin Peels Microdermabrasion Neck wrinkles Skin tags Thin lips Dry skin of body Dry cracked elbows / heels Length / Fullness of eyelashes Botox Fillers (Juvederm, Restylane, Belotero) Orchard Park Dermatology 3045 Southwestern Boulevard Orchard Park, New York (716)

8 Orchard Park Dermatology 3045 Southwestern Blvd, Suite 104, Orchard Park, New York 14127, Tel Financial Policy As a result of the Affordable Care Act most of our patients now have a balance due after their insurance has paid. Many patients have significant deductibles and co-insurance and will always have a balance but even patients with co-pay only plans may later owe additional co-pay for lab work such as pathology. Mailing and tracking more than 500 bills each month has become unmanageable for our staff so we are looking to control costs without compromising patient care. Long term patients know we have always maintained a large credentialed staff of providers and nurses in order to deliver the highest level of care to our patients in a clean comfortable private setting so when limited resources are diverted away from patient care it is a disadvantage for all. More and more private medical practices have adopted a credit card on file as a program to help control medical costs. Credit card on file is a secure payment method with no added costs for either the patient or medical office. Instead of receiving a bill, you receive a receipt. You already participate with a credit card on file every time you check into a hotel or rent a car. Our program is exactly the same and will also save you the time and postage required to mail in a payment. After your insurance company (or companies) have determined your portion of the bill, we will charge your credit card and a copy of the receipt will be ed or sent to you. Please note that no funds are held and your card will not be charged until you have a charge due. This in no way compromises your ability to dispute a charge or question your insurance company s determination of payment. You can choose not to leave a credit card on file in which case you should settle your account when you receive the Explanation of Benefits (EOB) notice from your insurance company. The EOB will tell you the exact amount that you owe and you can mail us a check or phone our office to make a credit card payment. If you choose traditional billing, be advised that we send only ONE statement and delinquent accounts will incur a $35.00 late fee. Almost all of our patients choose the convenience of credit card on file and we encourage you to do so as well. How will I know how much you are going to charge me? After insurance has paid their portion they will send you a notice titled "Explanation of Benefits" (EOB). This notice will read "This is not a bill", however, the amount listed under "Patient Responsibility" is the exact amount you owe Orchard Park Dermatology. This is your official notification that your insurance has paid their portion and that the remainder is now your responsibility. You may also call your insurance company to obtain this very same information. Then what? We receive the same notification that you do. It arrives days after your appointment. We look at each EOB carefully to see what your insurance has determined to be the patient responsibility. This is the same way we normally determine how much to bill you in the mail. But wait, I m nervous about leaving you my credit card. We do not store your sensitive credit card information in our office. It is stored encrypted on a secure gateway as required by law, just like any hotel or rental car agency. We contact this site only to process a payment and we never actually see your credit card number. What if I need to dispute my bill? We value our patients and will always be available to help you understand if there has been a mistake, and of course work with you if there is a billing error. We will only charge the amount that we are instructed to by your insurance carrier in the EOB they send to both you and us. Again, this is the same way that we normally determine how much to bill you in the mail. What is the easiest way to settle my account? When you receive your explanation of benefits, simply mail your check or contact our billing office during regular business hours and make a payment arrangement. (cash, check or credit card) Patients have the right to know what will be billed for procedures and may request anticipated costs. If you have questions about our office policy, please speak with our office biller, Melissa Szczepanski, at ext I have read and understand the above outlined financial policy. I agree to reimburse Orchard Park Dermatology the fee of any collection agency, which maybe based on a percentage at a maximum 25% of the debt and all costs and expenses, including reasonable attorney fees and court costs we incur in such collection efforts. The agency or law office may report to one or more credit reporting agencies. Please be aware that patients who miss appointments or do not cancel within 24 hour notice will be charged a fee: $75.00 for a regular appointment, $ for a cosmetic appointment. Please put my credit card on file. I choose not to keep a credit card on file. Patient Name: Signature: Date: Revised 9/1/2016

9 HOW CREDIT CARD ON FILE APPLIES TO YOUR INSURANCE Your Plan What You Do What Orchard Park Dermatology Does Medicare Place a credit card on file for We will file Medicare claim for you. patient responsible charges. Medicare and a secondary insurance Blue Cross/Blue Shield Univera Independent Health Empire/United Health Care Insurance we are not contracted with No Insurance No payment due at time of service. Place credit card on file for patient responsible charges. Pay co-pay. Obtain referral if one is required. Place a credit card on file for patient responsible charges. Pay co-pay. Obtain referral if one is required. Place a credit card on file for patient responsible charges. Pay co-pay. Place a credit card on file for patient responsible charges. Pay co-pay. Place a credit card on file for patient responsible charges. Pay for the visit in full at time of service. Pay for the visit in full at time of service. We will file Medicare and your secondary insurance claims for you. We will check your eligibility before every visit and file your Blue Cross/Blue Shield insurance claim for you. We will check your eligibility before every visit and file your Univera insurance claim for you. We will check your eligibility before every visit and file your Independent Health insurance claim for you. We will check your eligibility before every visit and file your Empire/United Health Care insurance claim for you. We will file your insurance claim for you and assign benefits to you so you will receive payment from your insurance plan. We will provide you a receipt. *Once your Insurance Company has determined your portion of the bill, we will run your Credit Card for that amount and you a receipt that same day. Other Fees: Failure to pay copay and/or charges on account: $50.00 Returned check fee: $50.00 No-Show Fee: Regular Appt. - $75.00 Cosmetic Appt. - $ Collection Fees: Administrative Fee - $ Collection Fee 33.3%

10 Understanding your Insurance What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if the policy has a $500 deductible, you must pay the first $500 of medical expenses before the insurance company begins to pay for any services. When does a deductible begin? Most plan years begin January 1 st, check with your insurance plan. When do I have to pay for services? Any time you receive medical care, you are expected to pay in full for the services until your deductible is met. How will I know when my deductible has been met? Call your insurance company at any time to check on how much of your deductible has been met; some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay. What is Coinsurance and How Does It Work? Coinsurance is your share of the costs of a health care service. It is the percentage of the bill your health insurance requires you to pay first and then they will pay the remainder of the bill. You start paying coinsurance after you ve paid your plans deductible amount. For example: You have a $1000 deductible. You have already met that deductible and need to have a skin cancer removed. The cost of removing the cancer is $500. If your coinsurance is 20 percent, you will pay $100 and your insurance will pay $400. What is a Dermatopathologist and What do I need to know? A Dermatopathologist is a medical doctor who specializes in looking at skin samples under a microscope. When a biopsy is taken it is sent to a Dermatopathology Lab and the biopsy is interpreted by a Dermatopathologist. You will get a separate bill directly from them. The bill you receive is not from our office, and you are responsible for all charges owed to them.