I request Sagaponack Medical P.C. dba Halsey Dermatology and its employees, practitioners and agents (collectively, “Halsey Dermatology”) to provide such care and administer such diagnostic and/or therapeutic procedures and treatments as, in judgment of Halsey Dermatology, is deemed necessary or advisable in my (the “Patient’s”) care. I understand this care may include tests, examinations, images, medical and surgical treatment, esthetic and cosmetic treatment, and related anesthesia. I acknowledge that no guarantee has been made to me as to the results that may be obtained from this care and that I can refuse services at any time. I understand if procedures are needed, the procedure will be discussed with me and my additional consent may be required.
I understand that Halsey Dermatology may help teach students and residents in healthcare. I agree that these students and residents may help in my care. I understand that I will be informed whenever possible of the resident or student status of specific caregivers.
I agree Halsey Dermatology is not responsible for my personal belongings and valuables.
FINANCIAL AGREEMENT
In consideration of services provided by Halsey Dermatology, I hereby assign and transfer to Halsey Dermatology any and all rights which I have against insurance companies, governmental agencies, or third party payers, for payment of charges for services Halsey Dermatology provides to me (Patient), and I authorize payment from all insurance or third party payers to go directly to Halsey Dermatology. I agree to pay for any care or services I (Patient) receive at Halsey Dermatology according to its rates and terms. If I am applying for payment under Medicare or Medicaid, I request that payment of authorized benefits be made on my behalf and assign the benefits payable for physician/medical services to the physicians/providers or organizations furnishing the services and authorize them to submit a claim to Medicare or Medicaid for payment. I understand that Halsey Dermatology will try to bill my insurance and others who may pay for my (Patient’s) medical care and that my insurance, including Medicare and Medicaid, should pay Halsey Dermatology directly for medically necessary services. Accounts are payable in full at time of service.
I understand that I may be responsible for copayment, deductibles and/or co-insurance at time of service. I may be responsible for other amounts the insurance company later determines I owe. If my insurance company denies payment, or will only pay a portion of the medical bill, I am responsible for payment of services rendered and will be billed accordingly. In order to insure this payment, Halsey Dermatology will store credit cards used to pay copayments and other charges on file with our PCI-compliant credit card processor. Halsey Dermatology requires at least one such credit card to be kept on file. Once my insurance company determines the exact amount which is my responsibility, Halsey Dermatology will send a bill/invoice for the amount due, and a second invoice approximately 30 days later. If payment is not received 45 days from the initial date of invoice, I request and authorize Halsey Dermatology to charge the balance due to credit card(s) stored on file on my (Patient’s) account. My signature below on this Terms of Registration form shall also serve as proof of my agreement to pay for any such charges according to the terms of my cardmember agreement. I understand results are not and cannot be guaranteed, and I expressly waive the right to contest charges with my credit card company on the basis of results, quality, or satisfaction.
If my insurance or other party does not pay, I understand I am responsible for my bill. If insurance payment is not received after 90 days, the balance in full becomes my responsibility. I understand that I am financially responsible for all cosmetic procedures and for services not covered by my insurance. I acknowledge that all charges may not be determined at time of service. If my bill is sent to collections or adjudicated, I agree to be responsible for all related costs, attorneys’ fees, and interest from date of service. I understand a $50 fee will be added to my account for all personal checks returned for insufficient funds.
I acknowledge that Halsey Dermatology follows Center for Medicare Services (CMS) guidelines with regard to preventive services coverage. CMS does not currently include a routine skin examination as part of its preventive services coverage. CMS has declared that it may “add preventive services coverage through the National Coverage Determination (NCD) process if the service meets all criteria:
- Reasonable and necessary for the prevention or early detection of illness or disability.
- Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF) Appropriate for individuals entitled to benefits under Part A or enrolled under Medicare Part B.”
The USPSTF currently does NOT recommend a routine skin examination as a preventive service. If I desire a screening examination, I agree to request this in writing in advance of my appointment and agree to a fee of $500 payable at the time of the visit. Otherwise, I agree that visits to examine or evaluate the skin due to lesions, rashes, injuries or other concerns deemed medically necessary (not cosmetic) are covered services under CMS guidelines and appropriate examination will be provided as part of Evaluation and Management CPT coding, which will be billed to the patient’s insurance or patient/guarantor accordingly.
I understand laboratory and radiology services from other healthcare providers may be needed and recommended to me. If I obtain these services, I understand that I have a choice of where I (Patient) receive these services and will receive a separate bill from the laboratory, radiologist, imaging center, or other provider.
Halsey Dermatology offers some services such as aesthetics and cosmetics that are also available by other providers in the community, including physicians without board certification, non-physicians, and nurse injectors with limited training. Receiving aesthetic treatments and cosmetic services at salons, spas, and other entities or providers not affiliated with Halsey Dermatology shall be at Patient’s own risk. Halsey Dermatology (1) does not manage and shall have no liability for complications, adverse effects, side effects, scarring or any other consequences or sequelae of aesthetic or cosmetic procedures conducted elsewhere; and (2) may determine that subsequent services from Halsey Dermatology will not be provided. Halsey Dermatology will not provide pre-clearance for procedures conducted by third parties.
USE OF PATIENT INFORMATION
By signing this document, I authorize Halsey Dermatology to release my (Patient’s) personal health information: to any requesting healthcare provider for my (Patient’s) further diagnosis, care or treatment or for that provider’s payment or health care operations purposes, to any person or entity which may be responsible for billing and/or collection of claims for medical services or products provided by Halsey Dermatology under an insurance or other contract or obligation; to any person or entity which is, or may be liable to Halsey Dermatology or me (Patient) for all or part of Halsey Dermatology’s charges, including, but not limited to, insurance companies, health maintenance organizations, workers’ compensation carriers, or other third party; any governmental agency or other organization responsible for oversight of Halsey Dermatology or third party payor; to any pharmacy, pharmacy benefit manager, or other third party responsible or involved with approval, dispensing, or prior authorization of medications, treatments, and medical devices, or, for Halsey Dermatology’s normal health care operations.
PHOTOGRAPH CONSENT AND RELEASE
Photographs are an important part of the medical record to document and keep track of skin exam findings, and to identify and keep track of sites of procedures. These photographs are stored in the Halsey Dermatology Electronic Health Record. Sometimes when skin cancer or other conditions are found, Halsey Dermatology may determine that subsequent care is needed by an outside dermatologist, a specialized dermatologic surgeon, a plastic surgeon, a surgical oncologist, and/or other providers outside his practice. Biopsy site photographs would then become important in coordinating care with these providers and entities outside of his practice. By signing below, I agree to the use and storage of my photographs in my patient record, and I consent to the release of photographs to such outside providers (as listed above) and their hospitals/practice entities. I also release and hold Halsey Dermatology harmless from any claims relating to the use or misuse of photographs by such third parties.
TELEMEDICINE
”Telemedicine” includes delivery of billable healthcare services, diagnosis, consultation, treatment, and education using telephone or 2-way audio-video (such as Google Meet, Zoom, or PocketPatient).
I understand that there are risks with telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my provider and Halsey Dermatology that:
- The transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted, accessed, or intercepted by unauthorized persons.
- Due to limited physical examination and decreased availability of diagnostic testing, telemedicine based encounters may not be as complete as face-to-face encounters in the office. Further, information transmitted may be insufficient to support appropriate decision-making by the physician/provider.
Nonetheless, telemedicine has benefits including a higher degree of convenience, access, and safety, and may be used to successfully bring about positive medical outcomes in practice.
I agree to only receive Telemedicine services from Halsey Dermatology when I am physically present in the State of New York. I understand that I am under no obligation to use Telemedicine services, and may instead choose to schedule in-person visits with Halsey Dermatology.
By signing this document, I acknowledge that I have been informed of the risks and benefits of optional telemedicine services should I choose to request these services.
COMMUNICATION POLICY AND CONSENT FOR AUTOMATED OR PRE-RECORDED CALLS
In an effort to make our office more accessible, our staff are reachable during business hours via electronic message via our secure Patient Portal (https://hderm.ema.md). We ask that these services not be used for urgent communication as responses may be delayed 1-2 business days (though we strive to address messages on the same business day when possible). If you have not received a response after 2 business days, you should call the office to ensure the communication was received. Appropriate uses for these services include scheduling appointments and non-urgent refill requests. Time-sensitive requests and communications should be made via telephone call to our office, or to 911 in case of emergency.
I acknowledge the text and electronic messaging policy and authorize Halsey Dermatology to communicate with me through text or email, even if not encrypted. I further consent to Halsey Dermatology accessing my medication history information electronically through a secure connection using Halsey Dermatology’s ePrescribing applications.
By supplying my home telephone number, mobile telephone number, email address, or other personal contact information, I consent to Halsey Dermatology’s use of such information, including the name of my health care provider, the time and place of my scheduled appointment(s) and other relevant information (and to disclose such information to the provider of any automated outreach and messaging system), for the purpose of notifying me of a pending appointment, a missed appointment, an overdue visit, balances due, lab results, and any other health care treatment, payment, marketing, or administrative matter. I consent to receiving more than one such messages per day. I consent to allowing messages (which may include the above information) to be left on my voicemail, answering system, or with another individual answering the telephone at any such number. I understand and acknowledge that the mobile phone carrier or other companies providing my telecommunications services may charge me fees for such calls and text messages. I understand that text messages are unencrypted and there is a risk that text messages could be read by an unintended third party while in transmission to me. Halsey Dermatology has contracted with Modernizing Medicine, Inc. or one of its affiliates (“MMI”), to provide a variety of services, including third-party outreach and messaging system using an automated or pre-recorded voice system. Halsey Dermatology may solicit, directly or through a third party, reviews, feedback, ratings and surveys for internal quality improvement and for publication. I agree that any reviews, feedback, ratings or surveys (both solicited and unsolicited) are derivative works of Halsey Dermatology, and I agree to fully and irrevocably, without compensation, transfer copyright of any past, current, or future reviews, feedback, ratings or surveys to Halsey Dermatology. I authorize Halsey Dermatology to release this signed agreement and its terms and contents to a third party when needed to enforce these terms.