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In-Office Interface 1-a

In-Office Visit Registration

INSTRUCTIONS:  Please complete the questions that follow.   
Please be sure to continue until the end. When you see the message "Thank you!"  you are all set!  If you do not get to this message, then please be aware that your responses have not yet been submitted and cannot be processed.
1. Have you been a patient either in office or via telemedicine at Massachusetts Dermatology Associates? *This question is required.
Please confirm that you would like to register as a NEW PATIENT to visit Massachusetts Dermatology Associates at our office in Beverly, MA. *This question is required.
Please confirm that you would like to schedule a FOLLOW-UP visit with Massachusetts Dermatology Associates at our office in Beverly, MA. *This question is required.
TERMS OF SERVICE AT MASSACHUSETTS DERMATOLOGY ASSOCIATES (MASSDERM):

To be seen as a patient at our office in Beverly, MA, please acknowledge the following terms:
  1. I have been provided access to "Notice of Privacy Practices" which can be found here.
  2. Photographs uploaded by me to MassDerm's online platforms as well as photographs taken by providers at MassDerm may be incorporated into my medical record.
  3. Staff from MassDerm may call and leave voicemail on my provided phone number(s) and send emails to my provided email address for appointment reminders, billing items and other issues pertaining to my care.  I also authorize MassDerm to share my medical information with other providers involved in my care.
  4. If I am unable to keep an appointment, I will provide a minimum of 24 hour notice.  This courtesy on my part will make it possible to give my appointment to another patient who needs it.  In the event that I am unable to give such notice, I may incur a no-show fee.
  5. Outside pathology, lab fees:  Biopsy, pathology and lab samples taken at the office and sent outside of our office for processing are billed independently of MassDerm.  If I undergo such procedures, I may receive a bill from the outside lab and will be responsible for payment to that facility.
  6. I understand that while MassDerm physicians contract with several insurance companies, it is my responsibility to verify with my plan that the physician I am seeing is a participating provider.  It is also my responsibility to verify the extent of my insurance coverage for various services offered at the practice.  I further understand that it is my responsibility to obtain necessary referrals and/or authorizations required by my insurance company.  If authorization is not obtained, I may be financially responsible for services rendered.   I acknowledge responsibility for all charges that my insurance does not cover.  I also hereby assign and authorize payment of medical benefits. Payments may be made on my behalf directly to Massachusetts Dermatology Associates, P.C. for services rendered.  I also authorize MassDerm to release necessary medical information to my insurance company, its agents, or any third party in order to determine payable benefits for the services rendered.

By choosing YES, I (the patient or patient's guardian) acknowledge that I have read and understand the information provided above, and I agree and hereby give my informed consent for treatment at Massachusetts Dermatology Associates. *This question is required.