Informed Consent for Medical Procedures
I hereby consent to any and all treatments that may be considered advisable or necessary in the judgement of the physician and physician’s assistant. Any procedure(s) done in this office can possibly cause risks such as: bleeding, painful irritation, recurrence, infection, scabbing, scarring and/or swelling. If your insurance does not cover the procedure(s), payment is your responsibility.
Financial Arrangements and Insurance
We are committed to providing you with the best possible care. If you have insurance, we are willing to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance, and your understanding of our payment policy. We emphasize, then, as health care providers; our relationship is with YOU, not your insurance company. It is necessary for you to be aware of your benefits.
You must also be aware of what laboratory your insurance covers. Lab tests are not included in the physicians' fee. The patient is responsible for all costs incurred by the lab which are not covered by their insurance. You will be billed separately by the lab for charges such as the appropriate copays or deductibles.
I authorize Rochester Dermatology Clinic to release any medical information necessary to process my insurance claim and I authorize payment of medical benefits to be made to the provider listed above for the services rendered.
If you have any questions about the above information, please do not hesitate to ask us. We are here to assist you.
I have read, understand and agree to the above financial policy.