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NEW IMAGE DERMATOLOGYAUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATIONAs part of your healthcare, this practice originates and maintains paper and/or electronic records describing your health history, symptoms, examinations, test results, diagnoses, and treatment, any plans for future care or treatment and payment for the services or treatment we provided. We use this information to:?Plan your care and treatment?Communicate with other health professionals or entities who contribute to your healthcare?Submit your diagnosis and treatment information for payment for the services or treatment provided to you “ONLY AS PERMITTED OR REQUIRED BY FEDERAL OR STATE LAW”, WE MAY USE YOUR PROTECTED HEALTHCARE INFORMATION TO DO THE FOLLOWING:To disclose, as may be necessary, your health information (including HIV+/AIDS status, drug/alcohol treatment/abuse notes and qualified mental health notes) to other healthcare providers and healthcare entities (such as: referrals to or consultation with, other healthcare professionals, laboratories, hospitals, etc.) or to others as may be required by law or court order concerning your treatment, payment and/or healthcare.To request from other healthcare entities and/or healthcare providers (i.e. doctors, dentists, hospitals, labs, imaging centers, etc.) specific healthcare information we may need for planning your care and treatment.To submit the necessary information to your insurance company(s) for coverage verification as well as the diagnosis and treatment information to your insurance company(s), other agencies and/or individual(s) for payment of our services or treatment we provided to you.To leave appointment reminders or other minimum necessary information related to your healthcare or healthcare payments on your answering machine, mobile voice mail, text mail, email or with a household family member. To discuss your health or payment information (only the minimum necessary in our judgment) with family members or other persons who are or may be involved with your healthcare treatment or payments.If you choose, please list by name and relationship the persons with whom we may share your healthcare or payment informationName: ____________________________Relationship:_______________________Phone #:___________________Name: ____________________________Relationship:_______________________Phone #:___________________Name: ____________________________Relationship:_______________________Phone #:___________________You may request a copy of and you have the right to read our “Notice of Patient Privacy Practices” prior to signing this authorization. The NPP provides a more complete description of health information uses and disclosures. The NPP is also provided in our lobby.I fully understand and agree to this authorization and acknowledge the above rights and disclosures.Patient Name (please print):________________________________________________________________________________________________________________ ________________________________________ _________________Signature Print name of person signing if other than patient Date*If other than patient is signing, are you the parent, legal guardian, legal custodian, or have a Healthcare Power of Attorney for the patient. Yes [ ] No [ ] RELATIONSHIP: ______________________________________________ Revised 06/04/20NEW IMAGE DERMATOLOGYAUTHORIZATION FOR THE USE OF PHOTOGRAPHY AND TESTIMONIALS In connection with the healthcare services that I, (patient name)_________________________________________, have received or shall be receiving, do hereby authorize photography (using current and accepted methods) may be taken of me or parts of my body (as defined by my healthcare provider), under the following conditions:My healthcare provider may take the photos, or they may be taken by a designee approved by my healthcare provider who has signed a HIPAA required Business Associate Agreement with my healthcare provider.The photography will be used for their medical records and if, in the judgement of my healthcare provider where needed. Please Initial: ___________I understand I have the right to revoke this authorization in writing, except to the extent that action has been taken in reliance on this authorization, or, if applicable, during a contestability period. In order for the revocation of this authorization to be effective, we must receive the revocation in writing. Please contact the office for specific details needed for revocation.I authorize my healthcare provider to acknowledge, to use or re-use, Testimonials/Reviews posted by me on social media (such as Facebook?, Twitter?, Google? etc.). I understand the testimonials may be posted on the healthcare providers social media outlet(s), the providers website or used as directed by my healthcare provider. This information will be used only in a professional and ethical manor as directed by my healthcare provider.Please Initial: _____________**We will accept written revocations of this authorization by Certified U.S. mail only.This Authorization shall be non-expiring, unless requested by patient. I fully understand and accept the terms of this authorization.________________________________________Relationship:___________________________Date:__________Patient’s Signature, Agent, or Representative’sRevised 06/04/20New Image Dermatology Payment PolicyTraditional Medicare, Medicare Advantage, Commercial, and/or Supplemental Plans: you will be responsible for paying your annual deductible and/or co-payment or charges for any non-covered service when that service is rendered. I authorize any holder of medical information to release to the above insurance carrier any information needed to determine these benefits or the benefits payable for services rendered including the SSA or HCFA. Regulations pertaining to Medicare assignment of benefits apply. Cash, check, or credit card will also be accepted for payment.Self-Pay or Non-Provider: If you are a self-pay patient or we are not providers for your insurance plan you will be required to pay in full at the time of your visit. We will not file claims to insurance companies that we are not contracted with. New Image Dermatology has adopted a new policy for patient payments. Like most businesses we now use a Credit Card Merchant Service which gives us the ability to swipe your credit/debit card to accept payment in the office and have the number securely stored on a remote server with PayJunction. The only information stored in our office with our secure, encrypted system, is the name on the card, the expiration date, and the last 4 digits of the card number. After receiving the explanation of benefits (EOB) from your insurance company informing our billing department of your balance due or credit balance on the account, they will automatically charge or refund your card. We will send you a receipt of any charges/refunds that are made to your card. To discuss any questions or concerns regarding your balance with us please contact the billing department at 727-845-3327. I further understand that if a payment is denied by my credit card company, I will not be able to schedule any future appointments with New Image Dermatology until the balance has been paid in full. I am aware that if any of my personal information has changed, I am responsible for notifying New Image Dermatology of any change to ensure they have the most current information to contact me or process my payment accurately.Your signature below signifies your understanding and willingness to comply with this policy.Signature:____________________________________________________________Date:_________________Revised 06/04/20 ................
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