Healthcare Dermatology Agreement

Healthcare Dermatology Agreement

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Please indicate if any apply:

History of bleeding disorder
Taking anticoagulant/antiplatelet medication
Immunocompromised
Pregnant or breastfeeding

Consent for Dermatologic Evaluation and Treatment

I authorize the dermatology provider and clinical staff to perform examination, diagnostic testing, and dermatologic treatments as deemed medically necessary. Treatments may include but are not limited to topical and systemic medications, cryotherapy, curettage, electrosurgery, chemical peels, intralesional injections, excisional biopsy, and suturing. I understand that treatment recommendations will be explained and that unforeseen conditions may require additional procedures.

I have been advised of the potential risks, complications, and common side effects associated with dermatologic procedures, which may include scarring, infection, bleeding, delayed healing, pigmentary changes, pain, allergic reaction, persistent numbness, or cosmetic irregularity. Although uncommon, serious complications can occur. I understand that no guarantee has been made as to the results of any procedure.

I understand alternative treatments may be available including observation, medical therapy, or referral to another specialist and that I may discuss these alternatives with my provider prior to treatment. I acknowledge I have had the opportunity to ask questions and that my questions have been answered to my satisfaction.

Photographic and Diagnostic Records

I authorize clinical photography, dermatoscopic images, and other diagnostic recordings of the treated area for the purpose of my medical record, treatment planning, and intra-office consultation. I understand such images are part of my medical record and may be used for education and quality improvement purposes if all identifiers are removed. I understand I may refuse photography for non-treatment purposes without affecting my access to care.

Consent to photography: I consent    I decline

Billing, Assignment and Financial Responsibility

I authorize release of medical information to my insurer and hereby assign benefits to the provider for services rendered. I understand I am responsible for copayments, deductibles, co-insurance, non-covered services, and charges denied by my insurer. Payment is due at the time of service unless prior financial arrangements have been made in writing.

I understand that pathology and laboratory fees for biopsies or specimens are billed separately by the outside laboratory and are my responsibility if not covered by insurance.

HIPAA Authorization and Privacy Acknowledgement

I acknowledge that I have been offered a copy of the practice's Notice of Privacy Practices. I understand that the provider may use and disclose my protected health information for treatment, payment, and healthcare operations consistent with the Notice. I authorize the practice to communicate appointment reminders and health information to the contact information provided on this form.

Acknowledgement of receipt: I acknowledge receipt of the Notice of Privacy Practices

Authorization and Expiration

I authorize the release of medical information necessary to process claims and to coordinate care. I authorize payment of benefits to the provider and consent to the described treatment. I understand I may revoke this authorization at any time by providing written notice, except to the extent action has already been taken in reliance on this authorization.

This authorization expires on:    If no date entered, authorization will expire one year from the date signed.

Consent Certification

By signing below I certify that I have read and understand this Healthcare Dermatology Agreement. I consent to the procedures, treatments, and uses of my health information as described. I affirm that the information I have provided on this form is true and accurate to the best of my knowledge.

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