• NEW PATIENT REGISTRATION

    • MEDICAL HISTORY  
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    • MEDICATIONS - Please enter all current medications, include OTC, vitamins and herbals:

    • Allergies: (Please enter all allergies)






    • Review of Systems: Are you currently experiencing any of the following? (Please check yes or no)

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    • WOMEN:

    • PLEASE INDICATE IF YOU...

    • PATIENT INFORMATION  
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    • Age :

    • In order to comply with federal "Meaningful Use" requirements, we must ask that you provide the following information:




    • INSURANCE/RELEASES  
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    • IN CASE OF EMERGENCY

    • PROTECTED HEALTH INFORMATION RELEASE

    • The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dermatology Associates of Ithaca or insurance company to release any information required to process my claims.

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    • GENERAL CONSENT  
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    • HIPAA COMPLIANCE STATEMENT - THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

      At Dermatology Associates of Ithaca we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities.

      UNDERSTANDING YOUR HEALTH RECORD/INFORMATION - Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care.

      YOUR RIGHTS - Although your medical chart belongs to our practice, the information contained in the chart is yours. You have the right to inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information.

      OUR RESPONSIBILITIES - We are required to maintain the privacy of your health information, send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.

      EXAMPLES OF HOW YOUR INFORMATION IS USED - Your health information will be recorded and used to plan your treatment. Reports may be sent to other doctors to help them plan your treatment. Bills will be sent to your insurance company. The information in the bills will include confidential information such as your name, address, diagnosis, and treatment. In providing your care, we may communicate with other individuals or businesses. Examples include other physicians and/or laboratories. To protect your privacy, we ask our business associates to safeguard your information.

      OTHER NOTICES - We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation
      insurance company. We may, from time to time, update these policies.

      FOR MORE INFORMATION OR TO REPORT A PROBLEM - If you have concerns or would like additional information, you may contact the practice’s Privacy Officer at (607) 257-1107.

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    • PAYMENTS POLICIES  
    • 1. Insurance. We participate with most major insurance plans, including Medicare. If you are not insured by a plan we participate with, payment in full is expected at each visit. If you are insured by a plan we participate with but do not have an up-to-date insurance card, payment in full may be required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

      2. Co-payment and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your copayment/deductible at each visit. If you are unable to pay at the time of service, your appointment may be rescheduled. 

      3. Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered medically necessary by Medicare or other insurers. You must pay for these services in full at the time of your visit.

      4. Proof of insurance. All patients must complete our patient information forms before seeing the provider. We must obtain a copy of a current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

      5. Claims submission. We will submit your claims and assist you in any reasonable way we can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

      6. Insurance changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

      7. Divorce. In case of divorce or separation, the party responsible for payment on the account is the parent authorizing treatment for a child. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent. We do not forward bills to other parties regardless of court rulings or divorce decrees.

      8. Returned Checks. There is a $25 fee for any check returned by the bank.

      9. Non-payment. If your account is over 90 days past due, we may refer your account to a collection agency and report it to the credit bureau.

      10. No Show/Cancellations. If you must cancel or reschedule an appointment, we ask that you call as soon as you can, preferably at least 48 hours before your scheduled appointment time. Failing to show up for your appointment or cancelling less than 24 hours in advance (unless extenuating circumstances) are both documented and subject to a cancellation fee ($30 for consultations/$50 for surgical appointments). After three "no shows," or "late cancellations" our policy is to discharge the patient from the practice.

      I have read and understand the payment policy and agree to abide by its guidelines.

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