FINANCIAL POLICY

Payment is required for all services. If you have insurance, your payment is based on your negotiated contracted rates with your insurance company. You are responsible for any copays, deductibles, coinsurance, any non-covered services, and usual and customary amounts for non-contracted insurance. Co payments and unpaid balances will be collected at the time of service at check-in. If you are unsure of your copay, deductible, or coinsurance amount, please contact your insurance company for clarification prior to your appointment. I understand that in the event that services are not covered under my insurance, I accept full financial responsibility for all non-covered services. For patients without insurance, $150.00 will be collected during check- in and the remaining balance based on the services provided will be collected at checkout. For cosmetic visits, a $150.00 cosmetic consultation fee will be charged when the appointment is made, this will be applied to the cosmetic service fee if a procedure is completed within 3 months. The remaining fee for the cosmetic service will be collected at checkout on the day of the procedure. Cosmetic fees are non refundable. You will be sent a statement to the physical address or email address you have on file. You will be responsible to contact the office if you have a change in either address. Once the final statement is sent, your account may be sent to our legal collection agency. I acknowledge that I shall be responsible for the collection agency fee or the actual collection cost to the practice. At this point, all contact regarding your account must then be made with the legal collection agency’s account representative. If you need to set up a payment plan, please call the office prior to your visit. I further acknowledge that There is a $25.00 banking fee for all returned checks.

REFERRAL POLICY

If a referral is required by my health insurance plan, I understand that it is my responsibility to obtain the referral from my primary care provider and assure that it is available at the time of my visit. I further understand that it is my responsibility to keep track of the number of visits I have used, the expiration date, and obtain a new referral as needed. I understand that should I fail to have a valid referral at the time of my visit, I will need to pay the cancellation fee and reschedule.

CANCELLATION POLICY

Should you be unable to keep the appointment, please cancel at least 24 hours prior to the appointment time. Cancellations must be on a business day. (i.e. Monday appointments need to be cancelled on Friday). Otherwise, there is a cancellation fee of $50 for general dermatology appointments & $100 for surgical and cosmetic dermatology appointments.

INSURANCE CARD POLICY

All patients new and returning are required to present their current insurance card(s) at every visit. I understand by signing below that I am responsible for notifying the office of any changes to my insurance or contact information.

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This summary of our privacy practices contains a condensed version of our Notice of Privacy Practices.

Our full length notice is available upon request. PLEASE REVIEW IT CAREFULLY. Effective Date: Today

This notice describes how medical information about you may be used and disclosed & how you may gain access to this information. We understand that your medical information is personal to you, and we are committed to protecting your information. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you as our patient. By law, we are required to make sure that your Protected Health Information is kept private.

How will we use or disclose your information? Here are a few examples:

If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information we maintain about you. These rights include:

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I wish to be seen for a dermatologic issue(s). I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the doctors and staff at Indigo Dermatology are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is inherent risk of becoming infected with COVID-19 by virtue of being seen in Indigo Dermatology's offices. I hereby acknowledge and assume this risk, and I give my express permission for Indigo Dermatology's doctors and staff to proceed with my upcoming visit(s).

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test. I understand that possible exposure to COVID-19 before/during/after my upcoming visit(s) may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death.

I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my upcoming visit(s).

Signature of Patient or Person Authorized to Sign for Patient

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