Patient details

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Medical history

Office Policy

it is the patient’s responsibility to know insurance eligibility and benefits. all copays, deductibles, and any other fee are due the day of service. no exceptions, we do not bill the patient.

all patients are required to provide a financial responsible party with a social security number for financial responsibility liability in case of payment not receive within a timely manner, after 120 days the account will be sent to a collection agency *fees will apply $15*

it is the patient’s responsibility to obtain any referral or authorizations if needed prior to their appointment.

if you arrive to your appointment 15 minutes late or later your appointment will be rescheduled.

it is the patient’s responsibility to contact our office if you are not able to keep your appointment. *fees will apply*

it is the patient’s responsibility to notify our office with any new information regarding the patient. (address, phone number, insurance etc.)

all calls will go through our triage department. the triage department will speak with our providers and/or the ma’s regarding your concerns and they will contact you (our staff are not able to speak to patients over the phone during office hours).

when requesting a letter or forms to be filled out by our staff please allow 3 business days for paperwork or letter to be completed.

when requesting medical records, we can give you access to the patient’s portal. if a printout is needed allow 7 business days. *fees will apply*

our office reserve the right to deny treatment to any patient whose unable to follow our office policy.

By signing this form, I hereby give my consent for Ciocca Dermatology, PA to use and disclose protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided describes such uses and disclosures more completely.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Ciocca Dermatology reserves the right to revise its Notice of Privacy Practices at any time. I understand any charges, copays, coinsurance and deductibles will be collected at the time of service. If I do not sign this consent, or later revoke it Ciocca Dermatology, PA may decline to provide treatment to me. There is a NOSHow fee. All accounts past due will be send to collections, collections fee will apply.

By signing this form I have read and understood all of the office policy. I agree to follow all policies and understand if I don't agree to the office policy I will not be accepted as a patient.

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Patient details

Medical history

Office Policy