INSURANCE AUTHORIZATION
My signature below indicates that I authorize Indigo Dermatology to release any pertinent medical or health information to the Social Security Administration or its intermediaries, carriers of Medical claims, or to my insurance carrier or its representative, necessary to process an insurance claim. I permit a copy of this authorization to be used in place of its original and request that payment of medical insurance benefits be made to Indigo Dermatology. Regulations pertaining to Medicare Assignment of benefits apply.
INDIGO DERMATOLOGY’S STATEMENT ON HIPAA
The Health Insurance Portability Accountability Act (HIPAA) was enacted to protect and enhance the rights of patients by providing them with access to their health information and controlling the inappropriate use of that information to reduce fraud and abuse, and to improve the quality of healthcare by restoring trust in the healthcare system.
APPOINTMENT POLICY
Appointments are reserved especially for you. Indigo Dermatology makes every effort to schedule times that accommodate your needs. Every effort is made to see all patients on time, barring any unforeseen emergencies. Indigo Dermatology asks that you make every effort to keep your appointment. If issues arise that conflict with your scheduled appointment, we ask you to call us to reschedule. Multiple missed appointments without notification make it impossible for our providers to maintain a treatment plan for our patients. Multiple “no-show, no call” for appointments may also result in a $45.00 “no show fee” applied directly to your account or a formal discharge from this practice. Your signature below indicates that you have read and agree to abide by the terms of Indigo Dermatology’s Appointment Policy.
FINANCIAL POLICY
Indigo Dermatology strives to maintain a high level of professional care while keeping the costs as fair as possible. Payment is expected at the time of treatment. We accept a Check or Credit Card with proper identification such as a valid driver’s license. We always accept cash. Most Health Insurance is accepted provided we can verify your eligibility for treatment by Indigo Dermatology, either before or at the time of your visit. If seeing us for primary care, it is the patient’s responsibility to make sure that Indigo Dermatology is listed as their PCP with their insurance if your plan requires a PCP be selected. All CO-PAYS and/or DEDUCTIBLES are collected at time of service. If a patient does not have the appropriate co-pay or payment amount, the appointment will be rescheduled to such time as the patient can make the appropriate payment. If you are seen without payment of your patient responsibility a $10 fee will be added to the balance each month until paid. Patient is 100% responsible for all fees incurred for services rendered. We will send a claim to your chosen insurance carrier for services rendered. If your insurance carrier does not make payment within 60 days from the date of treatment, the balance of your account will be shifted to the patient or responsible party for payment in full within 14 days. Failure to make payment or payment arrangements within 14 days may result in further collections processing.
