Consent to Leave Message
Skin MD, LLC, in order to comply with the HIPAA Privacy Regulation, requires an authorization from the patient before detailed messages are left for the patient. This policy is to protect the privacy of the patient and to protect the physicians and staff of Skin MD, LLC from violating the patient’s confidentiality. If there is not a signed consent on file, physicians and staff will only leave their name and telephone number on an answering machine, voicemail or with a live person answering the phone requesting the patient to return the call. By completing the consent below, you are allowing Skin MD, LLC physicians and its staff to leave a message on an answering machine, voicemail or with a specified individual. You may specify what information is left and with whom by noting the information on the bottom of this form. By signing, you are also consenting to the mailing or faxing of any results, requested by you, to your primary care physician or another physician involved in your care.
I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carrier any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply. In the event I am later found to be ineligible for any reason, I agree to pay for any and all services provided by Skin MD at their regular fees without any insurance adjustments.
I authorize my insurance company to pay benefits on my behalf directly to Skin MD. I authorize Skin MD to provide to my insurance company any information necessary to process claims for services rendered to me. In the event I am found to be ineligible for any reason, I agree to pay for any and all services provided by Skin MD at their regular fees without any insurance adjustments.
SELF-PAY/OUT OF NETWORK
I understand that I am a Self Pay patient due to the fact that either Skin MD is not contracted with my insurance company or I do not have insurance coverage. I will be responsible for filing my claim. Also, I must pay the full amount due at the end of my visit in order to receive 20% off of the total amount for medical services rendered. This discount does not apply for cosmetic services. Cosmetic services must be paid in full prior to treatment.
Our office only accepts Advocate Accountable Care (ACE), a form of Illinois Public Aid insurance. Other forms of Public Aid / Medicaid (for either primary or secondary insurance) are not accepted for new patients and therefore, we are unable to see
Public Aid / Medicaid patients who do not have ACE insurance.
OVERDUE BALANCE NOTIFICATION
Billing statements are sent to patients after insurance processes your claim. All patient balances are due within 30 days upon receipt of our billing statement. We may charge an Overdue Statement Fee of $5.00 for each monthly reminder we send to you. This may not apply for patients who have enrolled in our Easy Pay program.
After several attempts of collecting your balance and your balance remains delinquent, your account may be referred to an independent collection agency. If may account is sent to an independent collection agency, I agree to reimburse SkinMD, LLC the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all costs, and expenses, including reasonable attorney’s fees, we incur in such collection efforts.