New Patient Registration Form

Patient's Legal Name*

Date of Birth*

Age*

Social Security Number (optional)

Mailing Address*

City

State

ZIP

Email Address

Home Number

Work Number

Cell Number

Preference


May we call you as early as 8am?


By signing this form, I agree you may leave a message with test results or appointment reminders on my phone. I will inform you if this is not acceptable.

Parent or Guardian (if under 18)

Home Phone

Address (if different)


Emergency Contact:

Emergency Contact Relationship:

Emergency Contact Phone:


Person(s) allowed access to billing information and/or medical records:
(i.e.: to schedule/cancel appointments, billing questions, biopsy results, etc.)

Relationship:

Type of Access:

Expiration:


Primary Insurance*

Certificate/ID #*

Group/Account #*

Policyholder Name*

Relation to Policyholder*

Policyholder DOB*

CoPay *

Secondary Insurance

Certificate/ID #

Group/Account #

Policyholder Name

Relation to Policyholder

Policyholder DOB

CoPay


Thank you for choosing Four Seasons Dermatology. We look forward to establishing a lasting relationship as your dermatology provider. As part of this relationship, we wish to establish our expectations of your financial responsibility as outlined in this Financial Policy.

1. PAYMENT is expected at the time of your visit. Please note: any patient 18 years or older are financially responsible for their balance due. We accept cash, check, or credit card (Visa MasterCard, Discover). Payment will include any unmet deductible, co-insurance, co-payment, or non-covered charges from your insurance company. If you do not carry insurance or carry an insurance with which we do not participate, a 20%* discount will be provided for payment in full. Payment plans may be arranged with the Billing department.

*Please note that this 20% discount does not pertain to cosmetic procedures with Dr. Donald Laub. Payment is due in full at the time of the surgery.

2. INSURANCE. Patients must present current insurance cards and photo identification at the time of service, to prevent identity theft, prior to seeing the physician. We will submit claims to insurers with whom we participate. This office is required by Medicare and other insurance carriers to keep your signature on file authorizing us to file claims for you and to release information if the payer requires it for consideration of a claim.

Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for understanding their individual benefits and is responsible for any charges incurred as a patient with Four Seasons Dermatology. If your insurance company has not processed a claim on your behalf within 45 days, the balance will be transferred to your account and you will be responsible for payment. If we receive payment at a later date, you will be reimbursed by Four Seasons Dermatology. Insurance plans and Medicare consider some services to be “non-covered,” in which case you are responsible for payment in full.

Four Seasons Dermatology verifies patient insurance prior to the visit. However, it is your responsibility to know your benefits. It is your responsibility to know if your insurance plan requires a referral or a prior-authorization prior to services. If you are concerned with the cost of an evaluation or procedure, please discuss this prior to the service with the billing and claims department, NOT the provider.

3. COSMETIC SERVICES. Cosmetic procedures are not billable to insurers. All cosmetic services and products must be paid for at the time of service. A charge for an evaluation may be assessed in addition to the cost of the procedure.

4. PATHOLOGY SERVICES. Additional laboratory services may be necessary for certain evaluations and/or surgical procedures. Some pathology services are billed through our office with the exception of Fletcher Allen Health Care and Vermont Dermatopathology, which will bill your insurance company separately. We require a consent form to be signed prior to the service which will include laboratory information.

5. DELINQUENT ACCOUNTS. We make every effort to accommodate you when you are in need of medical care and expect that you will make every effort to pay your bill promptly. If you have a financial hardship or are unable to pay your bill in its entirety, please contact our billing office to discuss payment plan options. Returned checks will incur a $20.00 service charge. If your account is delinquent without you having established or met payment options with our billing office, your account will be turned over to a collection agency. A late fee of $25.00 will be added to cover the cost of multiple statements sent and the fee charged by the collection agency. Any collections accounts will need to be cleared before scheduling future appointments. Failure to maintain financial accounts in good standing may result in termination of medical care.

6. MISSED OR CANCELLED APPOINTMENTS. Patients that miss or cancel an appointment with less than 24-hour notice may be assessed a $50.00 charge. A missed surgical appointment may be assessed a $100.00 charge.

GENERAL CONSENT TO TREATMENT: By signing below, I authorize the health care providers at Four Seasons Dermatology, to conduct examinations, diagnostic tests and procedures to assess my health care conditions, and to provide care, services or therapies necessary to effectively diagnose and treat me. I understand that it is the responsibility of my treating health care provider(s) to explain to me the nature of proposed care, treatment, services, prescribed medications, suggested interventions, or procedures. Before I undergo particular procedures or tests, my provider(s) will explain the potential benefits, risks, or side effects, including potential problems that might occur during recuperation, the likelihood of achieving goals, reasonable alternatives, and the relevant risks, benefits, and the side effects related to alternatives, including the possible results of not choosing to undergo the recommended treatment.

I also assign payment directly to Four Seasons Dermatology of all benefits applicable and otherwise payable to me from my insurance carrier, HMO, or other third party payor, for services rendered by Four Seasons Dermatology. I understand that I am financially responsible to Four Seasons Dermatology for any and all charges that the carrier declines to pay (including but not limited to: not a covered benefit; disallowed by plan). I hereby authorize the release of my medical records as deemed necessary for payment of insurance benefits.

Signature*

Date


Steven R. Partilo, MD

Anita L. Licata, MD

Donald Laub, MD

David Gawlik, PA-C,

Brian Weinstein, PA-C

M. Elizabeth Hughes, PA-C

Leah Villemaire, PA-C

Betsy Benton, PA-C

Erin Primiano, PA-C