PATIENT INFORMATION: Office Hours: Monday and Wednesday: 8am-5pm; Tuesday and Thursday: 8am-6pm;   Friday: 8am-4pm Office Procedures: All patients are seen by appointment only. If you must cancel your appointment please give us at least 24 hours notice so that the time can be given to a patient with an immediate problem. Please be prompt, as a sincere attempt is made to see our patients at their scheduled time. Our office staff is experienced in answering most questions asked on the telephone. If necessary, the provider will be consulted and the answer relayed to you. Calls for the provider to return personally will be made after office hours unless time permits during the day. It is important for you to monitor your medications and call for refills before you run out. Prescription refill requests should be placed early in the day and you should allow a 24 hour turn around. Do not wait until your last dose of medication to call for a refill. Prescriptions cannot be refilled after office hours or on weekends. Our office policy is to limit telephone initiated prescription refills to within (1) year of the most recent office visits for oral medications and (3) years for most topical medications. Fees & Insurance: Our fees for all services rendered are standard for dermatology practices in the New England area. We participate with many insurance plans and submit claims to most insurance carriers. Some insurance companies pay fixed allowances for certain procedures and others pay a percentage of the charge. If you have an office co-payment please be prepared to pay it at the time of service. In addition, our office is considered a 'Specialty Office'. Please check with your insurance carrier to see if you need a medical referral to come to a 'Specialty Office' as if one is necessary it will be your responsibility to obtain it prior to your medical visit. If you are insured by a plan with which we do not participate, your insurance company will reimburse you directly. Please also note, we cannot be held responsible if your insurance plan has a Physician Assistant benefit exclusion. It is your responsibility to understand your benefit coverage and plan guidelines. If you do not have medical insurance and payment would cause you financial hardship, please let us know prior to your visit so that we can arrange a mutually agreeable payment plan.   PATIENT FORMS: Patient Registration | HIPAA Form   Print out the Forms: PATIENT INFORMATION REGISTRATION FORM: THIS SECTION MUST BE COMPLETED FOR ALL PATIENTS: Today's Date ____/____/____ Name ______________________________________________________________________________ Date of Birth: ____/____/____ Age: _____ Social Security #__________________Sex:  M / F Mailing Address : ___________________________________________________________________ Home Phone: ( )_______________________ Work Phone: ( )_______________________ Cell Phone: ( )_______________________     Other Phone: (   )______________________ Marital Status: ____Single____Married____Divorced____Widowed____Separated____Other Employer:_____________________________________________________________________ Emergency Contact:_____________________________________________________________ Medical History: *Are you allergic to any medications? _____Yes    ____No If yes, please list.:_______________________________________________________________ *Please list all pills, medicines or tablets you are taking:________________________________ *Is there anything else we should know about your health ? ______Yes _____No If YES, please list:_______________________________________________________________ *Did another Health Care Provider recommend that you see us today ? ____Yes ____No If yes, please list name:_______________________________________________________ Name of your Primary Care Provider:___________________________________________ Are you interested in discussing our skin care products or rejuvenation program? Yes or  No  RESPONSIBLE PARTY (if different from patient)-Must be completed in patient is a Minor Name: ___________________________________________________Date of Birth: ____/____/____ Home Phone: (     )_______________________ Work Phone: (     )_______________________  INSURANCE COVERAGE - PRIMARY: Insurance Co. Name:_____________________________________________________________ Name of Policy Holder (Insured):__________________________Insured SS#:______________ Policy Holder (Insured) Date of Birth: ____/____/____ Policy #__________________ Group Name or Number__________ If patient is a child, check relationship __Mother __Father ____Other  INSURANCE COVERAGE - SECONDARY: Insurance Co. Name:___________________________________________________ Name of Policy Holder (Insured):__________________________Insured SS#:___________ Policy Holder (Insured) Date of Birth: ____/____/____ Policy :________   Group Name or Number:_________________ If patient is child, check relationship:  Mother  Father  Other  RECEIPT OF NOTICE OF PRIVACY PRACTICES: My signature below indicates that I have received and/or reviewed a copy of my physician's Notice of Uses and Disclosures of Protected Medical Information (Notice of Privacy Practices). I have been given the option of signing a separate Patient Consent Form. Patient or Responsible Party Signature _____________________________ Date ____/____/____ PAYMENT POLICY: Medicare: We are participating providers of the Medicare program. We will accept assignment on all claims. Patients are responsible for meeting their annual $124.00 deductible and paying for the 20% copayment. We do file with secondary /supplemental carriers. However, in the event that the secondary does not pay within 60 days, patients will be balance billed. HMO, PPO or other Insurance patients: You will be responsible for paying your annual deductible, copayment and charges for any non-covered, cosmetic services, or services rendered without a valid medical referral. Patient or Responsible Party Signature _____________________________ Date ____/____/____ MEDICARE PATIENTS ONLY: This office is required to keep your signature on file authorizing us to file claims to Medicare for you and to release information to that payor if they require it for the proper consideration of a claim. Please read and sign the following statement: 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. Signature as it appears on Medicare Card _____________________________ Date ____/____/____ If you have a supplemental policy and it is a MEDIGAP policy to which your Medicare Carrier automatically 'crosses over', we are required to keep a separate signature on file: I request authorized MEDIGAP benefits be made on my behalf for any services furnished to me. I authorize any holder of medical information to release to the above MEDIGAP carrier any information needed to determine these benefits or the benefits payable for related services. Signature as it appears on MEDIGAP Card __________________________ Date ____/____/____  Consent to Treat Minor with Parent or Guardian Not Present During Visit: Patient Name:______________________________   Date of Birth:____________________ Please be advised that by signing the below consent, I am authorizing  Mitchell Schwartz or Phoebe Pelkey, PA-C  to see my minor child without the parent or legal guardian of the minor child being physically present. This shall be a standing visit release and does not expire. Adult/Guardian Name;________________________________________________________ Signed:_________________________________Date:_______________________________          Health Information Privace Act Patient Consent Form: (HIPAA FORM)   Dorset Street Dermatology Patient Consent for Use and Disclosure of Protected Health Information   With my consent, Dorset Street Dermatology may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Dorset Street Dermatology's Notice of Privacy Practices for a more complete description of such uses and disclosures.   I have the right to review the Notice of Privacy Practices prior to signing this consent. Dorset Street Dermatology reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Dorset Street Dermatology Privacy Officer at 329 Dorset Street, South Burlington, Vermont 05403.   With my consent, Dorset Street Dermatology may call my home or other designated location and leave a message on voice mail or in person in reference to any items taht assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results amoung others.   With my consent, Dorset Street Dermatology may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential.   With my consent, Dorset Street Dermatology may email to my home or other designated location any items that assisst the practice in carrying out TPO, such as appointment reminder cards and patient statments. I have the right to request that Dorset Street Dermatology restrict how it uses or discloses my pHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.   By signing this form, I am consenting to Dorset Street Dermatology's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. II I do not sign this consent, Dorset Street  Dermatology may decline to provide treatment to me.   ___________________________        ________________________ Signature of Parent or Legal Guardian      Patient's Name                  Date