10680 Medlock Bridge Rd., Suite 204
Johns Creek, GA 30097
Ph 470.282.5729 | Fax 770.674.5795
Dr. Paola Bonaccorsi | Dr. Dale Sarradet

  Welcome and thank you for choosing May River Dermatology, LLC

Effective treatment requires good communication. It is critical that the
New Patient Packet is completed thoroughly so we can meet your needs.


 
Overview of the forms
Demographic Information
Please document your personal information, emergency contact, pharmacy of preference and medical insurance information. We will scan your insurance cards and photo ID so please bring them in with you to your appointment.

Social and Medical History
Please provide us with your social, medical, family history and list of current medications.

HIPAA Consent
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule gives individuals a right to be informed of the privacy practices of their health plans and of most of their health care providers, as well as to be informed of their individual rights with respect to their protected health information (PHI). By signing this section of the form, you consent to our use and disclosure of PHI, payment and health care operations within medical offices and organizations involved with your care.

Third Party PHI authorization
This is an optional form. Please let us know the name of anyone (spouse, children, relatives, or friends) you would like to give permission to access and request your health record. If there is no one you would like to authorize please write “none” or put a line across the page and sign.

Billing Policy
This document outlines our standard billing practices. As a courtesy to our patients we will bill their health insurance carrier(s) for medically necessary visits and procedures. In order to do this properly and in a timely manner, we will need accurate insurance information. We also ask that you pay close attention to our policies regarding 1) coinsurance, co-pays, account balances and insufficient funds, 2) biopsies, and 3) the option to leave a credit card on file.

Maps and contact information for our Johns Creek office.
 
 

We look forward to seeing you soon.

Demographic Information
 
 
 
Social and Medical History

List all medications you are currently taking (including prescriptions, over-the-counter, & vitamins)

 

- Social History -


 

Past Medical History – Do you have any history of:*

 
    Hypertension
 
    Heart Disease
 
    Diabetes
 
    Asthma
 
    Arthritis
 
    Cancer
 
    Pacemaker
 
    Artificial valves

 
 
    Are you pregnant or breast feeding?
 
    Keloid scarring
 
    Problems with healing
 
    Skin disease (eczema, psoriasis, etc.)
 
    Atypical moles
 
    HIV positive
 
    Hepatitis C positive
 
    Problems with anesthesia
 

Surgical History:*

 
    Artificial hip joint
 
    Artificial knee
 

Family History:*

 
    Family history of skin cancer
 
    Family history of melanoma
 
    Family history of other skin diseases
 
 
 
 
 
HIPAA CONSENT
      Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.
      You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
      By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
 
The patient understands that:
  • Protected health information may be disclosed or used for treatment, payment, or health care operations
  • The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
  • The Practice reserves the right to change the Notice of Privacy Practices
  • The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
  • The patient may revoke this Consent in writing at any time and all future disclosures will then cease
  • The Practice may condition receipt of treatment upon the execution of this Consent.
 

This Consent was signed by:

Date *:
Please sign with your mouse, finger, or stylus
Patient or Legal Guardian Signature *
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION TO THIRD PARTY
(Complete this form if you would like for May River Dermatology, LLC to disclose certain protected health information to family members)

I,  ,
    authorize May River Dermatology, LLC to use and/or disclose certain protected health information (PHI) as described herein. I understand that, if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws.
   have reviewed this authorization and elected not to complete at this time.
BILLING POLICY

The following sets forth the general billing policy of May River Dermatology, LLC (“the clinic”). Please review this information and sign where indicated.

  • I understand that it is my responsibility to provide the clinic with current, accurate billing information at the time of check in and to notify the clinic of any changes in this information.
  • I understand that I will be charged a $50.00 no show fee for each missed appointment and $150 for any surgical appointment that is not cancelled with a minimum 24 hour notice.
  • A late fee of 1.5% per month (18% APR) may be assessed to any balance which remains unpaid 30 days after the statement date on which the balance first appears.
  • I understand that I am responsible for payment of my account at the time of service for deductibles, non-covered services, medically unnecessary services, copayments and insurance balances. It is my responsibility to know my specialist co-pay (which can be different than my Primary Care co-payment). I understand that this is a contractual agreement that I have with my health plan and that the clinic also has a contractual agreement with my health plan to collect co-pays at the time of service, and the clinic is required to report to the carrier any enrollees failing to pay the co-pay.
  • I understand that the clinic will attempt to obtain the necessary prior authorizations prior to rendering treatment. I further understand that prior authorization is not a guarantee of payment, and that I am responsible for any bills not paid by my insurance carrier.
  • I understand that if I present an insufficient funds check (NSF check) for payment on my account that I will be charged a $30 NSF fee. I further understand that to rectify my account, I will be required to pay with cash, a money order, cashier’s check, or credit card.
  • I understand that there may be a small fee to copy and mail medical records.
  • I understand it is the policy to collect the deductible and/or coinsurance prior to scheduling my surgical procedure. I further understand that THE FEE I AM QUOTED IS AN ESTIMATE based on 1) anticipated surgery to be performed and 2) current information provided to clinic by my insurance carrier.
 

Initials

*  Please be aware that if a biopsy is required at your visit, you will receive a separate bill for this service. The specimen is sent to a pathology lab, where a physician (pathologist) interprets the tissue. This physician will bill you directly for this service. If your insurance requires us to use a specific lab, you must notify us in advance of your visit and we will do our best to accommodate your needs. If you have any problems with your bill from the pathologist, please call our office and we will be happy to help you resolve the matter.
*  I understand that I will be billed for any amounts due by me (copayments/coinsurance/deductibles) and that I have a financial responsibility to pay these amounts. I understand that I will be provided with two (2) statements for any balance due after insurance payment. I further understand that if I have not made payment after the second statement is mailed, the account may be sent to an outside collection service. I authorize, in order to service my account, that I may be contacted at any telephone number associated with my account, including wireless telephone numbers. I also understand that I will be responsible for any collection, interest, or legal expenses associated with the collection efforts.
(OPTIONAL) I authorize the clinic to generate charges to my credit card for any unpaid balance without further permission or notice should my account fall into a 60 day or later (after the date of service) category. A receipt with detail explanation for any charges will be mailed to your home address. All personal information is protected by HIPAA and can only be used for purposes of treatment, payment, or healthcare operations.
 
Please provide your credit card to our front desk staff at check-in so they can save the card information using a secure and encrypted method.

My signature below confirms that I have read these billing policies and my financial obligation as pertains to May River Dermatology, LLC.

 
Date *:
Please sign with your mouse, finger, or stylus
Patient’s OR Insured’s Signature*
Maps and contact information for our Johns Creek office
JOHNS CREEK OFFICE
470-282-5729
10680 Medlock Bridge Road, Suite 204
Johns Creek, GA 30097
 
From Ga 400(headed south)
Take 400 towards Atlanta
Take exit 13 towards Norcross
Exit left off ramp towards Norcross
Onto Ga 141 (Peachtree Parkway)
Stay on 141 for approx.. 5.83 miles
At Parsons Rd. turn Rt
Take immediate Rt into Parsons Meadow Complex

From Winder/Athens/Dacula
Highway 316 towards 85
Take the Sugarloaf exit (exit after Riverside Pkwy)
Exit Right onto Sugarloaf
Turn Left onto Peachtree industrial (can only go left or right)
Turn Right onto Abbotts Bridge Road (QT gas station on the rt)
Go to Parsons Road and turn left this will be the second Light
Pass Northview Highschool on the Right
Go through the intersection of Parsons and 141
Immediate Right into Parsons Meadow Complex

From 285:
Take Peachtree Industrial Blvd/141N
Will come to fork in road stay to the left on 141 to Cumming Dahlonega
Pass the Atlanta Athletic Club on the Right
Continue 3 Miles to Parsons Road
Turn left onto Parsons Road (North View High School Is on the right)
Immediate Right into office complex (Parsons Meadow)