Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care.
Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:
Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.
Possible Risks: As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:
By signing this form, I understand the following:
I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby authorize Regency Physicians and a member of his or her staff to use telemedicine in the course of my diagnosis and treatment.
I. Consent for treatment: I authorize Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery its agents, Betty Hinderks Davis, MD Jason Mussman, MD, Benjamin Jones , MD, Brent Schultz, MD,Zoe MacIsaac, MD, Stephanie Spahr, PA-C & Brittany Silverman, PA-C to render treatment to me/my dependents for dermatological and medical/surgical care.
II. Assignment of Benefits/Release of medical information: I request that payment for authorized Medicare or other applicable private insurance benefits be paid directly to Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery for services provided under their care. I also authorize Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery to release necessary medical information to my insurance company, its agents, or any third party in order to determine pa
**Once your deductible is met, many insurance companies still do not pay 100% of the healthcare cost. If that is the case you will have a copay or co-insurance, which is a partial payment required by you in addition to what the insurance company will pay. It can be from 10-50% of the allowed amount until you have accumulated enough medical bills to meet your yearly out-of-pocket maximum.
***This is an estimated portion that is due. Unfortunately we don’t know exactly what your insurance will cover or what you will be billed until your claim is processed.
If you have any questions regarding your financial responsibilities please ask or call our billing department at Regency Dermatology: 623-243-9077 Regency Plastic Surgery: 623-322-0730
V. Referrals/Authorization: I understand that if my insurance company requires a referral, I am responsible for obtaining a referral prior to my visit. If I do not have a referral at the time of service, no services will be rendered until I obtain a referral or sign a waiver of financial responsibility. Payment in full is required at the time of service.
VI. Missed Appointments: Our office requires 24 hour notice for cancellations. Patients who fail to show to the initial visit will be forgiven, If a patient chooses to schedule a second appointment we will place a credit card on file and If the second appointment is missed we will process the credit card on file for $75.00 (non refundable). If a third no show or cancellation/reschedule with no 24 hour notice should occur the patient will be charged $90.00. If a fourth should occur the patient will be charged $100.00 and be dismissed from Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery.
I have reviewed the statements above and understand my responsibilities.
At Regency Skin Institute PLLC; DBA Regency Dermatology and/or Mussman PLLC; DBA Regency Plastic Surgery we are committed to protecting your privacy. We comply with all federal, state, and local laws. This notice describes how we use your health information. It describes some of your rights and some of our responsibilities.
Each time you visit our offices, we record your symptoms, physical examination, test results, diagnosis, and treatment. This information enables us to: plan for your care, communicate with others who care for you, report to your insurance carrier, bill for our work, and improve the quality of our care.
Although your paper chart belongs to our practice, the information contained in the chart is yours. You have the right to: inspect your records, obtain a copy of your chart for a small fee, correct your records, and tell us not to release your information.
We are required to: maintain the privacy of your health information; send needed health information to other medical providers, and release information to insurance companies, certain government agencies, and others. We may be required to release some information, even without your permission.
We may leave a message at your home, at your business, on your answering machine or on your voicemail. We may mail you a postcard or other written notices. We may need to disclose your information to your family members or other people helping with your care. In doing so, we will use our best judgment. We may disclose information to others as required by law or if subpoenaed. If you were injured on the job, we will need to disclose your health information to your workers compensation insurance company. We may, from time to time, update these policies.
FOR MORE INFORMATION OR TO REPORT A PROBLEM If you have concerns or would like additional information, you may contact the practice’s Office Manager at (623)243-9077.
A physician must notify a patient that the physician has a direct financial interest in a separate diagnostic or treatment agency to which the physician is referring the patient and/or in the non- routine goods or services being prescribed by the physician, and whether these are available elsewhere on a competitive basis. A.R.S. §32-1401(27)(gg). (I/We) support this law, because it helps patients make reasoned financial decisions concerning their medical care.
You are being referred to/from (Regency Dermatology/Regency Plastic Surgery) to (Regency Dermatology/Regency Plastic Surgery). While A.R.S. §32-1401(27)(gg) may not directly apply depending on the referral source, (I/we) wish to advise you of Dr. Mussman’s financial interest in these entities so that you can make an informed decision about your care.
Regency Dermatology is a trade name owned by Regency Skin Institute, PLLC. Dr. Jason L. Mussman owns, controls and has a financial interest in Regency Skin Institute, PLLC.
Regency Plastic Surgery is a trade name owned by Mussman, PLLC. Dr. Jason L. Mussman, as Co-Trustee of the Mussman Family Living Trust, owns, controls and has a financial interest in Mussman, PLLC.
Further, as indicated below, goods or services (I/We) have prescribed are available elsewhere on a competitive basis.
THESE SERVICES AVAILABLE ELSEWHERE ON A COMPETITIVE BASIS
Surgery Centers and Hospitals
The law provides for the acknowledgement of your having read and understood these disclosures by dating and signing this form in the spaces provided below. (I/We) will keep the signed original in your patient file; you will receive a copy.
ACKNOWLEDGEMENT: (I/We) have read this “Notice to Patients” form, and (I/We) understand the disclosures that it contains.
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