I authorize the release of any medical information necessary to process any claim. I authorize payment of medical benefits to Hudson Dermatology P.C. for services.

I request that payment of authorized Medicare benefits be made directly to Hudson Dermatology P.C. for services provided to me. I authorize any holder of my medical information to release to the Health Care Financing Administration and its agents any information needed determine these benefits and benefits for related services.

I have read the payment policies at http://hudsondermatology.com/payment-policies and understand and agree to abide by them. Specifically:

1) I am financially responsible for all charges for any and all services rendered. If Hudson Dermatology participates with my insurance plan, Hudson Dermatology will bill my insurance and I will be responsible for any charges remaining after the insurance reimbursement has been processed. I further understand that I am responsible for payment for services that are considered non-covered expenses by my insurer.

2) I understand that my co-payment is due at the time of my visit and that there will be a $5 handling charge if the co-payment needs to be collected after my visit. If my annual deductible has not been met, I agree to authorize a $75 charge for the first visit and $50 for the following visits. If a check is returned as not payable, I will be responsible for the amount of the check plus a fee of $35.

3) I understand and agree that it is my responsibility to know if my insurance requires a referral and that it is my responsibility to obtain the referral before the appointment. I understand that if I do not obtain or do not have a referral on file I am responsible for payment for services.

4) If Hudson Dermatology does not participate with my insurance plan, I will be seen as a private-pay patient and my payment is due at the time of the appointment, unless alternate arrangements have been made in advance. I authorize Hudson Dermatology to charge my credit card and I understand that my credit card information will be saved in a secure way for future payments.

5) Hudson Dermatology confirms all appointments by email and/or text. I understand and agree that there is a $45 fee for general dermatology appointments, a $90 fee for surgical appointments, and a $150 fee for Mohs surgery appointments missed or canceled with less than 24 hours notice.

Hudson Dermatology requires patients to keep a credit card on file with our office. We run our payments through our electronic health record system, Modernizing Medicine, which is a HIPAA compliant secure credit card processor. When we scan your card, your payment information will be stored on ModMed secure servers and available for future transactions. Our office staff will not have access to your card. Only the last four numbers will show in our system. A valid credit card, debit card, HSA or FSA card will be accepted.

Your credit card on file will be used to pay account balances after insurance adjudication or provide refunds. Once your insurance processed your claims, they will send an Explanation of Benefits (EOB) to both you and our office showing your total patient responsibility. You typically receive the EOB before we do, so if you disagree with the patient responsibility amount owed, it is your responsibility to contact your insurance carrier immediately.

Our Payment Policy states you are responsible for paying claims not covered by your insurance company. This is just another form of collecting that payment. Nothing is changing about how much you pay. When you come to our office and receive a service, you do so with the understanding that you are ultimately responsible for the cost of your care.

Authorization

I authorize Hudson Dermatology, PC to charge my credit card outstanding amounts for services rendered that my insurance company identifies as my financial responsibility. This authorization relates to all payments not covered by my insurance company for services provided to me by Hudson Dermatology, PC providers.

This authorization will remain in effect until I cancel this authorization. To cancel, I must give a 30-day notification in writing and the account must be in good standing.

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my Protected Health Information. I understand that the information can and will be used to:

• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from third party payers.
• Conduct normal healthcare operations such as quality assessments and physician certifications.

You have informed me of your Notice of Privacy Practices www.hudsondermatology.com/privacy-practices, which contains a more complete description of the uses and disclosures of my health information. I have been given the right to read and review your Notice of Privacy Practices before signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact the organ

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations and I also understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Please sign by typing your name and date of birth.