Patient Forms & Policies

Preparation for Appointments:

• Required Items: Please bring your driver’s license/photo ID, health insurance card(s), a method of payment, and a list of your medications to every appointment.
• Information Updates: Inform our receptionist of any changes to your contact details, insurance information, or financial status to avoid being charged for services not covered by your insurer.
• Arrival Time: Arrive 15 minutes early to ensure timely processing before your appointment.

Scheduling Appointments:

• Online Scheduling: Utilize our online scheduling system at https://galtderm.janeapp.com/ for convenience. If you are uncertain about which appointment type to choose, please call us at 954-463-5406 for guidance.
• Appointment Types: Select “Full Body Skin Exam” if you have multiple concerns to address in one visit. This ensures adequate time is allocated for a comprehensive examination.
• Surgical Appointments: These must be scheduled via phone or in person due to the specific nature of each procedure.

Missed Appointments and Scheduling Details:

• No-show Policy: A $100 fee is charged for appointments missed without 24-hour notice, except in emergency situations, which are evaluated on a case-by-case basis.
• Appointment Duration: Medical dermatology visits are set for 15 or 30 minutes, with new patients receiving a 30-minute initial consultation. Surgical appointments are determined in 20-minute increments, reflecting the procedure’s complexity. Concierge medicine appointments vary in duration based on patient needs.

Medicare and Insurance Policy:

• Concierge Primary Care and Medicare/Medicaid: Our concierge primary care does not accept commercial insurance, Medicare, or Medicaid. Patients opting for our concierge services must acknowledge that these services are not covered by Medicare or Medicaid and agree not to file claims for these services.
• Medicare Billing: For dermatology services, patients with Medicare are billed through their insurance. Patients are responsible for covering 20% of the Medicare-approved amount unless they have secondary insurance. We do not participate with Medicare Advantage HMO plans.
• Deductibles and Non-Covered Services: Dermatology patients are responsible for their Medicare deductible and charges for services not covered by Medicare, including cosmetic procedures.
• Insurance Disputes: Any disputes regarding coverage or benefits should be addressed directly with your insurance provider. Claims unpaid by insurance 61 days post-submission are the patient’s responsibility.

Private Insurance, Self-Pay, and No Insurance:

• Out-of-Network Status: Galt Dermatology & Concierge Medicine is out of network with private insurance companies. Patients must pay directly for services received.
• Payment Structure: Payment for dermatology services is due at the time of service, according to our direct care pricing. Concierge medicine charges are handled through a monthly membership fee.
• Fee Schedules: Detailed pricing for medical and surgical dermatology services is available on our website. Additional charges for specific administrative tasks will be communicated in advance.

Payment Policies:

• Immediate Payment: Payment is required at the time of service for any charges that fall under the patient’s responsibility. This may vary based on the individual’s insurance plan.
• Concierge Medicine Billing: Patients enrolled in our concierge medicine services are billed monthly, consistent with our membership-based approach.

Payment Methods and Policies:

• Accepted Payments: We accept cash, credit cards, and funds from Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) for medically necessary services.
• Credit Card Policy: For certain appointments, we require a credit card on file. This card will only be charged if our cancellation policy is breached or if a deposit is necessary for securing your appointment. We will inform you in advance if a deposit is required.
• HSA/FSA: Patients can use HSA or FSA accounts to pay for all services deemed medically necessary.

Secure Payment Processing:

• Online Payments: We utilize Square and JaneApp for secure online payments, analytics, and business operations. These platforms may collect information about the devices used to connect to their services, which helps enhance security and prevent fraud.
• Privacy Information: For more details on how your data is handled, you can access Square’s privacy policy at Square’s Privacy Policy and JaneApp’s at JaneApp’s Privacy Policy.
• Credit Card on File: A credit card is required to be on file through our secure processing system when scheduling an appointment, ensuring a smooth and efficient billing process.

Cosmetic, Aesthetician, and Elective Procedures:

• Fee Schedule: Payment is due at the time of service, with some procedures requiring a deposit.

Lab and Pathology Fees:

• Options: Choose between our discounted rate or using your insurance for pathology services. Concierge patients without insurance receive discounted lab fees at Quest Labs.

• Patient Responsibility: Please be aware that any lab or hospital services are agreements directly between you and the respective facility. Our practice is not involved in these agreements.
• Insurance Coverage: It’s crucial for patients to understand their insurance coverage regarding lab and hospital services. You are responsible for determining which services are covered and obtaining an Explanation of Benefits (EOB) from your insurance provider to clarify this coverage.

Cancellation Policy:

• Notice: A 24-hour notice is required to cancel or reschedule appointments, with instructions available online or by phone.
• Fees: A $100 fee is charged for late cancellations or no-shows, except in case of emergencies.

Ways In Which We May Use And Disclose Your Protected Health Information

Appointment Reminders — We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment.

Treatment Alternatives — We will use and disclose your protected health information to tell you about or to recommend possible alternative treatments or options that may be of interest to you.

Others Involved In Your Care — We will use and disclose your protected health information to a family member, relative, close friend, or any other person you identify who is involved in your medical care or payment for care. No information can be disclosed unless authorized by you for each individual.

Research — We will use and disclose your protected health information to researchers provided the study has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

As Required By Law — We will use and disclose your protected health information when required by federal, state, or local law. You will be notified of any such disclosures.

To Avert A Serious Threat To Public Health Or Safety — We will use and disclose your protected health information to a public health authority that is permitted to collect or receive information to control disease, injury, or disability. If directed by the health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Workers Compensation — We will use and disclose your protected health information for Worker’s Compensation or similar programs that provide benefits for work-related injuries or illnesses. Our concierge medicine service does not participate in workers’ compensation cases. These specific cases require attention from physicians designated by the patient’s employer.

Inmates — We will disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care; to protect the health and safety of others; or for the safety and security of the correctional institution.

Your Health Information Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have a right to:

• A Paper Copy Of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by visiting our website.
• Inspect and Copy. You have the right to inspect and copy the protected health information that we maintain about you and our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. Any psychotherapy notes that may have been included in the records we received about you are not available for your inspection or copying by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.
• Request Amendment. You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and the reasoning that supports your request

*We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if:

• • The information was not created by us, or the person who created it is no longer available to make an amendment
  • The information is not part of the record which you are permitted to inspect and copy
  • The information is not part of the designated records kept by this practice
  • If it is the opinion of the healthcare physician that the information is not accurate or complete
• Request Restrictions. You have the right to request a restriction or limitation on how we use or disclose your medical information for treatment, payment, or healthcare operations. For example, you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing to our practice manager.

*We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will comply with your request unless that information is needed for emergency treatment.

• An Accounting Of Disclosures. You have the right to request a list of the disclosures of your health information we have made outside our practice that were not for treatment, payment, or healthcare operations. Your request must be made in writing and must state the time for the requested information. You may not request information for any dates before April 14, 2003 (the compliance date for the federal regulation) nor for a period of time greater than six years (our legal obligation to retain information).

*Your first request for a list of disclosures within 12 months will be free. If you request an additional list within 12 months of the initial request, we may charge you a fee for the cost of providing the following list. We will notify you of such costs and allow you to withdraw your request before any costs are incurred.

• Request Confidential Communications. You have the right to request how we communicate with you to preserve your privacy. For example, you may request that we call you only at your work number or by email. Your request must be made in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests.
• File A Complaint. If you believe we have violated your medical information privacy rights, you have a right to file a complaint with our practice manager or directly to the Secretary of Health and Human Services.

Use Or Disclosures Not Covered

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such consent in writing at any time, and we no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the consent before the revocation are not affected by the revocation.

Effective Date: April 14, 2003.