In the event that Infinity Dermatology, PLLC is unable to reach me by phone, I authorize the release of information regarding appointments, procedures, medications, pathology or laboratory results to:

The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of your medical information for treatment, payment and healthcare operations. This is a summary of our Patient Privacy Policy including our compliance to HIPAA. Infinity Dermatology PLLC can provide copies of our Patient Privacy Policy if requested. This document explains how your medical information may be used and disclosed and how you can get access to this information.

Examples of how we will utilize your medical information include but are not limited to medical treatment, appointment reminders, consulting with your pharmacy. insurance claims, Worker’s Compensation claims, obtaining payment for services and in emergency situations.

At Infinity Dermatology PLLC, we understand the importance of your medical information and the privacy of this information. We are committed and dedicated to protecting your personal and medical information. Your medical record will be kept secure. We are required by law to ensure the privacy of your protected health information. By signing this consent, you agree that you have reviewed our Patient Privacy Policy.

You have the right to refuse to sign this consent. If you believe your privacy rights have been violated, you may file a written complaint to the Secretary of the Department of Health and Human Services and/or to the Infinity Dermatology PLLC office. You will not be penalized for submitting a complaint.

Description:
“No Show” is defined as any patient who fails to arrive for a scheduled appointment.

“Same Day Cancellation” is defined as any patient who cancels an appointment less than 24 hours before their scheduled appointment.

“Late” is defined as any patient who arrives at the clinic 10 minutes after the scheduled appointment time.

It is the policy of Infinity Dermatology to manage appointment no-shows and late cancellations. Infinity Dermatology’s goal is to provide excellent care to each patient while being respectful of everyone’s time. If it is necessary to cancel an appointment, patients are encouraged to contact the clinic as soon as possible.

Procedure:
1. The patient will be notified of this policy at the time the visit is scheduled. This policy can and will be provided in writing to patients at their request.

2. Established Patients:
a. Appointments are strongly encouraged to be cancelled greater than or equal to 24 hours prior to the scheduled appointment time.
b. If a patient “no shows” for an appointment, a $25 charge will be added to their account per occurrence.
c. If the patient arrives 10 minutes after the scheduled appointment time, they will be asked to reschedule, or wait if there is a vacancy later in the day.
d. If a patient has three consecutive no shows or same day cancellations, the patient may be subject to dismissal from Infinity Dermatology. Dismissals are determined by the provider only.

3. New Patients:
a. Appointments are strongly encouraged to be cancelled greater than or equal to 24 hours prior to the scheduled appointment time.
b. If a patient “no shows” for an appointment, a $25 charge will be added to their account per occurrence.
c. If the patient arrives 10 minutes after the scheduled appointment time, they will be rescheduled to a later date.
d. If a patient has three consecutive no shows or same day cancellations, the patient may be subject to dismissal from Infinity Dermatology. Dismissals are determined by the provider only.

Self-Pay:
Defined as any individual who does not have insurance coverage. Infinity Dermatology reserves the right to make adjustments in unique circumstances. It is the policy of Infinity Dermatology that if a patient does not have insurance, they will be required to pay a deposit prior to being seen in the clinic. Any patient who is unwilling or unable to pay the deposit will be rescheduled to a time when they can make the required payment or triaged to determine if emergency care is required, which will take place at the nearest Emergency Department.

Required deposit for visits are as follows:
Regular Follow up visit: $75.00
Preventative or Full Skin Check: $125.00
Elective procedure: 50% down prior to procedure A 25% discount will be given if paid in full at the time of service.
Insured: Defined as an individual who has insurance that will cover all or a portion of any medical bill.

Infinity Dermatology will bill health insurance carriers given all necessary information be provided. It is the responsibility of the patient to be aware of any exclusions, co-payments and deductibles related to the active insurance plan.

Co-Pays are due same day of each clinic visit. It is the policy of Infinity Dermatology that the patient is responsible for any portion of charges unpaid by insurance and must remit payment within 30 days of received statement. If the patient cannot remit payment within 30 days, Infinity Dermatology asks that the patient contact the office to set up a payment option.

Payment options are as follows:
• If your balance is $0-$100 you owe 100% of amount due
• If your balance is $101-$200 you owe $50 per month
• If your balance is $201-$500 you owe $75 per month
• If your balance is $500-$1,000 you owe $100 per month
• If your balance is $1,001-$2,000 you owe $125 per month
• If your balance is above $2,000 you owe $150 per month

If no payment is received, and no payment plan has been setup within 90 days of first statement, the remaining balance will be sent to a collection agency.