Patient Forms - Arsenault Dermatology

Patient Resources

New Patient / Registration Forms

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Our Office Policies

Equal Opportunity

Thank you for entrusting us with your health care. As we hope you are already discovering from our gracious setting and inviting, knowledgeable staff, all of us at Arsenault Dermatology are sincerely committed to providing you excellent care. We value all of our patients and look forward to doing everything possible to ensure you have a wonderful experience.

Please read and initial all of the following policies. These office policies are designed to clearly communicate our services. Our office is exceptionally efficient and we strive to ensure that all of our patients have an equal opportunity to receive the best service possible.

HIPAA – Health Information Portability and Accountability Act

We protect your privacy in every way possible. Our office strictly adheres to the HIPAA law. All employees are fully trained on HIPAA guidelines and all of our office technology is carefully designed to provide maximum protection of your personal information. We never share your information with anyone not directly involved with your care, insurance or billing without your consent.

All patients must complete and sign our HIPAA policy form. All patients are also requested to present their photo ID at each visit. These are HIPAA requirements specifically designed to protect your identity from misuse. Please refer to our “Notice of Privacy Practices” posted in the lobby and on our website.

Cancellation Policy

We strive to provide exceptional medical care in a timely manner. Our staff understands your time is precious and that changes may occur with little notice. To efficiently serve all of our patients we require a 24-hour notice for all cancellations. This provides us enough time to offer your valuable appointment time to another patient. Late arrivals may be asked to reschedule.

Appointments cancelled with less than 24-hours notice may be charged a cancellation fee.

Surgery / Cosmetic visit $100
Skin check / Focused visit $25

As a courtesy to you, the first no-show fee may be waived based on circumstances. It is our strong desire to create a lasting relationship built on mutual respect. We do everything we can to accommodate your schedule and we thank you in advance for your cooperation.

Minors

All minors must be accompanied by a parent or legal guardian on their first visit. After the first visit, a waiver can be signed to allow us to continue active treatment for the minor without the parent/legal guardian present at future visits. If you are interested, please ask our staff for more information.

Prescription Refills

Please allow us up to two days to process your refill request. Most refills are generally completed within one business day. To maintain the highest clinical standards, we require at least an annual exam for prescription refills. Your provider may require more frequent visits depending upon the medical condition.

The fastest way to obtain your refill is for your pharmacist to directly fax/email the request.

Prescription refills are a routine procedure and we gladly perform them during normal business hours. Any refill requests made after-hours (ie. on the emergency line) may incur an additional fee.

Financial Policy

We adhere to a clear and comprehensive financial policy. As a courtesy to all of our patients, it is our normal practice to:

Verify eligibility and benefits prior to your appointment.
File your claim with Medicare and/or commercial healthcare insurance providers.

For All Patients

Payment is required at the time of service unless prior arrangements have been made.
I am responsible for knowing the terms of my policy, including deductibles, copayments, coinsurances and any applicable referral procedures.
I am financially responsible for all charges, whether or not covered by insurance. This includes, but not limited to, out-of-network and cosmetic service charges. 9 All pathology and/or laboratory fees are billed independently of Dermatology at Lakewood Ranch and are ultimately my responsibility.
Patients with overdue accounts will be contacted by Arsenault Dermatology’s billing department. Every effort is made to help our patients satisfy their obligations in a reasonable manner.
I understand and agree it may be necessary to obtain tissue or perform lab tests to confirm a diagnosis or to determine a course of treatment. If any tissue is removed for a pathology examination or if a laboratory test (lab work, culture, etc.) is done in the office, the actual test is usually carried out by someone else. This means I MAY RECEIVE A SEPARATE BILL FROM PATHOLOGIST OR LAB FOR THESE TESTS. It is necessary to contact that lab directly to resolve any billing concerns.
In the event we are unable to verify your benefits or you cannot provide proof of coverage at the time of visit, I can either:

Reschedule my appointment, or
Make payment in full. We will provide financial statements to help you pursue reimbursement of the claim (upon request).

Option 1 – Medicare

My initial here and full signature below indicates that I hereby:

Authorize Arsenault Dermatology to release all information necessary to process my claims to CMS and its agents.
Assign any insurance payments (both Medicare and Medigap insurances) to be paid directly to Arsenault Dermatology.
Understand this Assignment will remain in effect until revoked by me in writing. I also understand that:
All Medicare beneficiaries without Medigap (ie. secondary insurance) coverage are responsible for paying the required 20% copayment at the time of service.

Option 2 – Commercial Insurances (ie. HMO, PPO, HSA)

Arsenault Dermatology will release all information necessary to process my claims to my insurance company and its agents

Assign any insurance payments (both primary and secondary insurances) to be paid directly to Arsenault Dermatology Understand this Assignment will remain in effect until revoked by me in writing. I also understand that:

My healthcare insurance is a contract between my insurer and me.
It is my responsibility to verify benefits for my particular plan and to make certain all proper authorizations have been obtained.
If I do not obtain the necessary referral I understand that I am solely responsible for all costs of the services provided.
It is my responsibility to satisfy any outstanding balances at the time of service, including: annual deductibles, copayments, out-of-network costs and/or coinsurances.

Option 3 – Self-Pay Policy

Dr. Arsenault extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of her self-pay patients. Arsenault Dermatology Self-Pay Policy requires self-pay patients to pay $100 upon check-in.

At the end of the visit:

Any charges in excess of the collected amount must be satisfied.
Any overpayments made will be refunded. Dr. Arsenault extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of her self-pay patients.

Self-pay patients may be eligible for discounted rates with local pathology laboratories.

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Effective Date: September 8th, 2016

Your Rights

You have the right to:

Get a copy of your paper or electronic medical record
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

Tell family and friends about your condition
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds

Our Uses and Disclosures

We may use and share your information as we:

Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting us using the information on page 1.
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues

We can share health information about you for certain situations such as:

Preventing disease
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

For workers’ compensation claims
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information.
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Contact Us

For further questions or concerns regarding this notification please contact the office. If you have an issue to report please submit in writing to one or both of the following individuals. Please make sure to include details of any incident and your contact information for follow up.

Privacy Officer and Practice Manager

Eva Fekete
Arsenault Dermatology
8926 77th Terrace East, Suite 101
Lakewood Ranch South, FL 34202
Email: [email protected]

Security Officer/COO/CTO

Mike Arsenault, MD, MBA
Arsenault Dermatology
8926 77th Terrace East, Suite 101
Lakewood Ranch South, FL 34202
Email: [email protected]