Patient Information

Insurance & Financing

Release of Medical/Billing Information Authorization Form

CHOOSE ONE:

• I authorize Advanced Skin & Laser Center to release my medical and billing information to the individuals listed below.
• I DO NOT authorize Advanced Skin & Laser Center to release my medical records and billing information to anyone other than myself.

The HIPAA privacy rule permits health care providers to communicate with patients regarding their health care, including protected health information (PHI) and billing information. This includes communication with the patient through mail, phone, fax or some other manner.

I understand that Advanced Skin & Laser Center is permitted by the HIPAA privacy rule to leave information regarding my appointment, including the date and time, on any phone number provided. Advanced Skin & Laser Center may request a return phone call to our office when speaking to any individual that answers the phone. If I only want confidential communication between Advanced Skin & Laser Center and myself, I must provide written notice to Advanced Skin & Laser Center on a form provided upon my request.

I understand that it is my responsibility to keep Advanced Skin & Laser Center informed of any changes to this information and that I may revoke this authorization at any time by written notice to Advanced Skin & Laser Center on a form provided upon my request.

Revised 09/24/2019

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Privacy Policy

NOTICE OF PRIVACY PRACTICES

HEALTH INFORMATION PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICALINFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW  IT CAREFULLY.

The Health Insurance Portability & Accountability Act of 1996, as amended by the HITECH Act and the final omnibus rule (“HIPAA”}, is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. HIPAA gives you significant rights to understand and control how your health information is used. HIPAA provides penalties for covered entities and business associates that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

The following are situations where the law allows us to make use or disclosure of your health information without obtaining your permission:

We may use and disclose yourmedical records for each of the following purposes:treatment, payment, and health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include case management.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be adjudicating a claim and reimbursing a provider for an office visit.
• Health care operations include the business aspects of running the Plan, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you without your prior authorization unless such communications are considered to be “marketing” as described below.

In some instances, we may contract with business associates for the payment and health care operations services we provide. For example, we may use an outside company to administer and manage the Plan. We may disclose your health information to our business associates so that they can perform the work that we ask them to. However, to protect your health information, we require that our business associates protect the privacy of your information and HIPAA requires that they do so as well.

Uses or Disclosures Required or Permitted by Law. We may use or disclose health information if the law requires us to use or disclose it for certain reasons. We may also disclose health information if a state law requires us to audit or monitor situations and for licensing or certifying health care facilities or professionals.

Public Health Authorities. We may disclose your health information to public health authorities that need the information to prevent or control disease, injury, or disability or handle situations where children are abused or neglected.

Food and Drug Administration(FDA). We may disclose health information when there are problems with a product that is regulated by the FDA. For instance, when the product has harmed someone, is defective, or needs to be recalled, we may disclose certain information.

Communicable Diseases. We may disclose health information to a person who has been exposed to a communicable disease or may be at risk of spreading or contracting a disease or condition. Employment-Related Situations. We may disclose health information to an employer when thee mployer is allowed by law to have that information for work­ related reasons. We may also disclose health information for workers’ compensation programs.

Disclosures About Victims of Abuse, Neglect, or Domestic Violence. We may disclose health information to appropriate authorities if we have reason to believe that a person has been a victim of abuse, neglect, or domestic violence.

Disclosures/or Health Care Oversight. We may disclose health information so that government agencies can monitor or oversee the health care system and government benefit programs and be sure that certain health care entities are following regulatory programs or civil rights laws like they should.

Disclosures for Judicial or Administrative Proceedings. We may disclose health information in a court or other type of legal proceeding if it is requested through a legal process, such as a court order or a subpoena.

Disclosures for Law Enforcement Purposes. We may disclose health information to law enforcement if it is required by law; if needed to help identify or locate a suspect, fugitive, material witness, or missing person; if it is about an individual who is or is suspected to be the victim of a crime; if we think that a death may have resulted from criminal conduct; or if we think the information is evidence that criminal conduct occurred on our premises.

Uses or Disclosures in Situations Involving Decedents. We may use or disclose health information to coroners, medical examiners, or funeral directors so that they can carry out their responsibilities.

Uses or Disclosures Relating to Organ Donation. We may use or disclose health information to organizations involved in organ donation or organ transplants.

Uses or Disclosures Relating to Research. We may use or disclose health information for research purposes if the privacy of the information will be protected in the research.

Uses or Disclosures to Avert Serious Threat to Health or Safety. We may use or disclose your health information to appropriate persons or authorities if we have reason to believe it is needed to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Updated 10/2022

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Advanced Skin and Laser Center

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE

By signing this form, you acknowledge receipt of the Notice of Privacy Practices from Advanced Skin & Laser Center. The Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. The Notice of Privacy Practices is subject to change. If the Notice is changed, you may obtain a revised copy by visiting our website at www.advancedskinlaser.com or on request from our staff.

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Financial Policy

PATIENT FINANCIAL POLICY

Thank you for choosing Advanced Skin & Laser Center for all of your skin care needs. We are dedicated to providing the best possible care and services for you and regard your understanding of your financial responsibilities as an essential element of your care. Please read the following carefully and sign at the bottom to confirm your understanding.

1. I) Insurance: We currently accept ONLY traditional Medicare and select commercial insurance plans. (Ask our office staff for an up-to-date list of in-network insurance plans.) You will be responsible at the time of service for the payment of: Co-Payments, Deductibles, Past Due Balances

1. Pathology: is ordered by Dr. Binhlam and/or our providers to properly diagnose certain skin disorders. To increase the quality of care for our patients, we utilize outside labs. The analysis of these specimens is then performed by a board-certified Dermatopathologist who specializes in the microscopic diagnosis of skin disorders. Charges for these services are billed by the lab or submitted to your insurance.

2. Cancellation/ No-Show Policy

1. 1. Office visit- I understand that it is my responsibility to cancel my appointment 24 hours in advance of my appointment date and time. I understand that if I no-show my office appointment, I will be charged the fee below.
      • Fee is $100.00 that you are responsible for and is not covered by your insurance plan
      • Arrival 20 minutes past scheduled appointment time is also considered a no-show.
   2. Surgical appointments- I understand it is my responsibility to cancel or change my appointment 5 business days prior to my appointment time and date. I understand that if I no-show my surgical appointment, I will be charged the fee below.
      • Fee is $250.00 that you are responsible for and is not covered by your insurance plan.
   3. Cosmetic procedures
      • All procedures, which are time intensive and cost $500 or more, will require a 50% deposit to schedule an appointment. Patients who NO SHOW or cancel without giving a 5-business day notice will lose their deposit.

3. Requests for Medical Records and Completion of Forms (such as Cancer Policy, Disability, etc): Medical records will be charged a fee of$20. Completion of forms are subject to a fee of$25. Upon receipt of payment, documentation will be returned or can be picked up within 3-5 business days, unless otherwise notified.

4. Methods of payment accepted are

1. 1. Cash, Visa, Mastercard, American Express, Discover
   2. Personal checks with proper identification (valid Driver’s License or photo ID). A $30.00 overdraft charge will be added to the insufficient funds amount of any returned checks

5. Delinquent Accounts: If your bill is unpaid or your insurance does not pay appropriately within a month of the service, you will be responsible for payment in full. A collection agency may be chosen to manage delinquent accounts. If your account is placed with a collection agency, you will be responsible for all costs of the collection services as well.

I have read the financial policies of ASLC and understand my financial responsibilities as a patient. I understand that failure to make payment when due is the basis for legal action and agree to pay any and all costs of collection, including court cost and attorney fees. The signature below confirms agreement to the above as a patient or the responsible party for the patient.

Revised 09/24/2019

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