New Patient Form

ASSIGNMENT OF BENEFITS

I authorize all insurance benefits be paid to the provider rendering services on behalf of Texas Dermatology and Laser Specialist, I understand for payment for professional services, including co-payments, deductibles and fees for cosmetic services, are due at time services are rendered.

HIPAA CONSENT

I hereby permit Texas Dermatology and Laser Specialists to use my health information, and/or to disclose my health information to any third-party payor (health insurance company), or to any party involved in my health care. I understand that there is a Notice of Privacy Practices in the practice reception area available for me to read. This consent shall be in force and effect as long as I am a patient at this practice. I understand that I have the right to revoke this consent, in writing, at any time by sending such written notification to my physician(s) at this practice. I understand the information used or disclosed pursuant to this consent may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I also understand that I have the right to: Inspect or copy the protected health information to be used or disclosed as permitted under federal law; refuse to sign this consent form.

EMAIL CONSENT

I understand that by providing my email address on my patient data sheet, I am subject to receiving email communication from Texas Dermatology and Laser Specialists but can request to be removed from the mailing list at any time.

PAYMENTS

Patient responsibility is expected at the time services are rendered. This includes all deductibles, coinsurance, co-payments, and any non-covered services such as cosmetic procedures. Upon in office check-out, Texas Dermatology will collect payment from you based on your insurance plan fee schedule, and available benefit information, but is only an estimate and your insurance plan will determine the final amount due. It should be noted that any procedure performed in the office, such as freezing a wart or performing a biopsy on a mole is considered “office surgery” by most major insurance carriers and may be subject to your deductible. We do not accept cash or check payments, and a card on file is required to reserve appointments.

Autopayment Authorization For Insurance Claims

Following each service, Texas Dermatology will submit any relevant insurance claim on behalf of the patient to the insurance company. Patients using insurance as a form of payment are required to authorize an autopayment of any remaining insurance balance via the payment terminal during in-office check-in.

Once your insurance company processes your claim, Texas Dermatology's autopay system will automatically process payment for any remaining patient responsibility 10 days after the claim has been processed and received by our billing department. All autopay information is fully encrypted and tokenized for insurance claims only.

You will receive an e-statement notifying you of any remaining balance from your visit 10 days prior to autopay processing. To change or cancel your autopay authorization, you must call us directly or email us at billing@texasdls.com.

NO SHOW/ LATE POLICY

If you are unable to attend an appointment, please let us know as soon as possible. We ask for at least 48 hours' notice for the cancellation of all appointments. We reserve the right to charge the following "late cancellation fees" or "no show fees" of $75 for office visits including consultations, and $300 for procedures, surgeries or cosmetic treatment appointment.

As a courtesy, we make every effort to confirm appointments in advance; however, it remains patient responsibility to know and to keep appointments. If you are more than 15 minutes late to your scheduled appointment, we will make every effort to work you back into the providers' schedule. However, we may have no choice but to reschedule your appointment.

Patients who miss three appointments in a 12-month period without providing 48-hour notice may be dismissed from the practice and no longer eligible to schedule with Texas Dermatology or Texas Dermatology Med Spa. We understand that emergencies happen. To avoid a no-show fee or dismissal from the practice, please notify us at least 48 hours in advance if you need to cancel or reschedule

AUTHORIZATIONS & REFERRALS:

It is the patient's responsibility to ensure that all required insurance authorizations and/or referrals are in place prior to their appointment. Please verify with your insurance plan whether a referral or authorization is needed for services at Texas Dermatology.

Failure to provide valid documentation at the time of service may result in claim denial. Any balance resulting from a denied claim due to missing or invalid authorization and/or referral will be billed to the patient based on our self-pay fee schedule.

CLAIM DENIALS:

Texas Dermatology will bill patient insurance plans as a courtesy to our patients. It is patient responsibility to ensure information provided is true and accurate. You must confirm with your insurance company that our group is in-network with your policy prior to your scheduled appointment.

To avoid claim denials, please submit all primary, secondary, and tertiary insurance information to us. If your claim is denied for any reason, you will be billed for services rendered based on a self-pay fee schedule.

PATHOLOGY/LABWORK

Pathology readings and blood testing are ordered by our physicians to properly diagnose and treat certain skin disorders. Charges for these services are billed to your insurance by the pathologist or processing lab.

Your skin sample or bloodwork may be sent to one of the following labs: Pathology Watch, Aurora Diagnostics: (South Texas Dermatopathology), Quest Diagnostics, Pathology Reference Lab, Sagis, or LabCorp.

Our providers make every effort to send lab work to the corresponding lab authorized by your insurance company. However, if you have a specific lab you wish to use, please inform your provider in the exam room at the time of testing

REQUESTS FOR MEDICAL RECORDS and COMPLETION OF FORMS

You may access most medical records through your online patient portal at no cost to you by visiting https://txdermandlaser.ema.md/ema/PatientLogin.action There will be a charge of $35.00 per paper request. Upon receipt of payment, documentation will be returned or can be picked up within 5-7 business days.

COSMETIC APPOINTMENTS

Cosmetic consultation appointments do not include time for treatment. Your provider will assess your skin and recommend a treatment plan based on your skincare goals during your consultation.

Some patients are recommended to start a dermatologic treatment plan before beginning cosmetic treatments, so that the underlying skin condition can be treated first. There is no additional fee for the dermatologic treatment plan recommended by a dermatologist or physician assistant.

A late cancellation fee of $300 will be charged if an appointment is cancelled within 48 hours of the reserved appointment time. Late arrivals past 15 minutes are subject to be rescheduled or worked in on the same day if possible. Any missed appointments will be charged in full.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

We are required by law to provide you with a copy of our Notice of Privacy Practices. If you would like a copy of this policy, please ask the front desk receptionist. To ensure that our records are accurate, please sign this form and return it to our receptionist to acknowledge that you have been provided with a copy of our Notice.

ADA Policy Acknowledgement and Accommodation Request

Texas Dermatology is committed to compliance with federal and state laws prohibiting discrimination on the basis of disability in the offering or delivery of healthcare services. Texas Dermatology recognizes its legal obligation to ensure effective communication with persons with disabilities and makes every effort to proactively assess communication needs as well as providing the most compassionate care.

Texas Dermatology staff will take appropriate steps to ensure persons with disabilities, including persons who may be deaf or hard of hearing, have an equal opportunity to obtain healthcare services with Texas Dermatology. This includes patients and their companions. Please review our policy and procedures which can be found at texasdls.com under Patient Resources.