New Patient / Registration Forms
- New Patient Paperwork (Adult)
- New Patient Paperwork (Minor)
- Consent to Treat a Minor
- Authorization to Release Information
- Surgery Instructions
- Wound Care Instructions
- Liquid Nitrogen Treatment
- Change of Address
- Notice of Privacy Practice
All of the forms provided are in Adobe PDF format. If you need to install a free copy of Adobe Reader, click here.
Our Office Policies
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 Goodless 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.
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.
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.
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.
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 Goodless 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 Goodless 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 Goodless 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)
Goodless 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 Goodless 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
Goodless Dermatology extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of their self-pay patients. Goodless 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. Goodless Dermatology extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of their self-pay patients.
Self-pay patients may be eligible for discounted rates with local pathology laboratories.