Insurance / Guarantor Information
24 Hour Cancellation & "No Show" Fee Policy
Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, Skin Health Forever Dermatology reserves the right to charge a fee of $25.00 for all missed appointments (“no shows”) and appointments which, absent of a compelling reason, are not cancelled with a 24-hour advance notice. “No show” fees will be billed to the patient. This fee is not covered by insurance, and must be paid prior to your next appointment. Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients. By signing below, you acknowledge that you have received this notice and understand this policy.
I hereby authorize Thomas M. Taylor MD to render treatment to me. I hereby Authorize Payment of medical benefits to Thomas M. Taylor MD. I hereby agree to pay any fee incurred in the course of my treatment; as such services are rendered to Thomas M. Taylor MD. I hereby authorize any physician or hospital to release records to Thomas M. Taylor MD. I hereby authorize Thomas M. Taylor MD to release medical records to any physician or hospital upon written request for such information.
History and Intake
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Payment for Medical Services
Most of our patients have health insurance coverage. Some of our patients have such coverage through health maintenance organizations. Regardless of any health insurance coverage, a patient receiving health care services is financially responsible for any health care services that are not covered by insurance.
With respect to any health care services that are not covered by your health insurance policy, payment is due at the time the services are rendered. Co-payments and deductibles are payable at the time health care services are rendered. As a courtesy, our office files insurance claims on behalf of our patients; however, the responsibility of paying our office for any health care services that are not covered by your health insurance is your responsibility. If for some reason you are unable to pay in full for any health care services, you should contact our billing department to make payment arrangements.
If you do not pay us for health care services in a timely manner, we reserve the right to charge interest at the rate of six percent (6%) per annum on any unpaid balance. Our office may turn over any unpaid balance for collection. We accept cash, personal checks, MasterCard, Visa, American Express, and Discover. If we receive a worthless check, our office will charge the maximum service charge permitted by law and our office may file a collection action with respect to the worthless check.
Notice of Privacy Policies
*THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS TO THIS INFORMATION.
- Allowed uses and disclosures of your medical information:
- Thomas M. Taylor MD, PA may use or disclose protected health information for the purposes of treatment, payment, or
healthcare operations, for example communications with healthcare providers and submission of health insurance
- Thomas M. Taylor MD, PA may use or disclose personal health information for the following reasons:
- Use and disclosure for public health activities
- Reporting about victims of abuse, neglect, or domestic violence
- Disclosures for law enforcement purposes
- Disclosure for judicial and administrative proceeding
- Disclosure to avert a serious threat to health or safety
- Additional uses disclosures:
- Thomas M. Taylor MD, PA may contact the patient to provide appointment reminders or information about treatment
alternatives or other health related benefits and services that may be of interest to the patient.
- You have the right to:
- Request restrictions on certain uses and disclosures, however, we are not required to agree to any requested restriction
- Receive confidential communications from us upon written request
- Inspect and request copies of your medical information
- Receive an accounting of any disclosures made, upon written request
- Receive a paper copy of the notice upon request
- We are responsible for:
- Maintaining the privacy of your medical information
- Providing this notice
- Abiding by the terms of this notice
- Providing written notice of any changes to this notice
You may complain to us or to the Health and Human Services Secretary if you believe that your privacy has been violated. If you wish to file a complaint with us, please provide the office manager with a written notice of how you believe we violated your privacy. All notices received will be investigated and reviewed by a physician. We will respond within two weeks, and we will not retaliate for any allegations made.
Upon your authorization, we may disclose your complete medical information, including pathology and billing information, to a requesting entity, such as an attorney, another provider, or a relative. Unless otherwise specified, we reserve the right to release as much information as we feel necessary pertaining to the request. You may revoke any authorization you make at any time, except to the extent that it was already relied on.