Patient Forms and Policies

Patient Registration Form

Download and bring a completed copy to your appointment

Scheduling Policy

Financial Policy

Notice of Privacy Practices

Office COVID-19 Protocols

Scheduling Policy

GENERAL SCHEDULING POLICIES 

  • Please bring the following items with you to each appointment
    • Driver’s License / Photo ID
    • Health Insurance Card(s)
    • Method of Payment
    • Medication List
  • Please inform the receptionist of any demographic changes: phone number, address, insurance information, etc. Failure to notify us of changes in demographic information, financial status, and/or insurance coverage, may result in you being responsible for any services not covered by your insurance carrier.
  • Please arrive 15 minutes early for your appointment.
  • Scheduling for surgical appointments must be made via phone or in-person.
  • No-show. Appointments missed without 24-hour notice will result in a $100 charge. One exception to this is an emergency and these are determined on a case-by-case basis at the discretion of our office.

SCHEDULING POLICIES SPECIFIC TO PATIENTS OF PETER L. BABINSKI MD, PA

  • Patients covered by Medicare or Positive Healthcare (PHP) are seen under the dermatology practice of Peter L. Babinski MD, PA., which shares office space with Galt Dermatology. If you are a Medicare patient or a PHP patient, please call our office to schedule. Do not use the online scheduling system.

SCHEDULING POLICIES SPECIFIC TO PATIENTS OF GALT DERMATOLOGY

  • Galt Dermatology uses our Time For Your Skin™ direct care time base appointments. Medical dermatology appointments are either 15 minute or 30-minute visits. All new patients will be scheduled for an initial 30-minute appointment. Surgical appointments are based on 20-minute increments based on surgical complexity. Please refer to the medical dermatology and surgical dermatology pages on our website for specific pricing of services.
  • Online scheduling. Galt Dermatology uses Acuity online scheduling system. We have signed a business associate agreement with Acuity, which is a legal contract that describes how the business associate (Acuity) adheres to HIPAA and protecting your information. You can access their full privacy policy at https://acuityscheduling.com/privacy.php.
  • Please select the Full Body Skin Exam appointment if you have multiple concerns that you would like to address during your visit.
  • If your concern is not listed or if you are unclear which appointment to select, please call us at 954-463-5406 to schedule.

Financial Policy

Medicare and Positive Healthcare (PHP) Patients:

  • By law, patients that are covered by Medicare or by Positive Healthcare (PHP) must be billed through their insurance under the practice or Peter L. Babinski MD, PA.
  • You are responsible for 20% of Medicare’s approved amount unless you provide our office with secondary insurance coverage at the time of your service.
  • You are also responsible for your Medicare annual deductible, as well as any charges for non-Medicare covered or cosmetic services.
  • We are required to file with your primary insurance carrier only. As a courtesy to our patients, we will file a claim with your secondary insurance. The medical insurance you supply to our office must be accurate and up to date.
  • Your insurance coverage and benefits are a contract between you and your insurance company. Therefore, all disputes must be handled between you and your insurance company.
  • Claims are submitted promptly after treatment is rendered, and if not paid by the patient’s insurance by the 61st day after submission of claim, it will be billed in full to the patient.
  • It is a felony to discount or waive copays and deductibles. We will not commit medical insurance fraud and do not give copay or deductible discounts or waivers.

Private Insurance/Self Pay/ No Insurance:

  • Patients covered by a private health insurance and patients without health insurance are seen and billed under Galt Dermatology. Galt Dermatology is a direct care practice, meaning we do not participate and are considered out of network with any private or government healthcare agency.
  • Patients pay Galt Dermatology directly for the care they receive at the time of service under our Time For Your Skin™billing model. Fee schedules for medical and surgical services are posted on the medical dermatology and surgical dermatology pages, respectively.
  • For patients covered by a commercial health insurance that are seen and billed under the practice of Galt Dermatology, upon request, we can provide the necessary information for you to file a claim with your insurance company (there is a small charge to cover the physician’s time). However, we cannot guarantee that your insurance company will reimburse you. All questions regarding your insurance coverage and reimbursement should be directed toward your insurance company or benefits manager.
  • Occasionally, there may be an additional fee for staff time, administrative work, or other extra tasks that are done on your behalf. We will inform you BEFOREHAND if extra fees are involved. These include medical coding fees ($25 per request) and prior authorization work for prescriptions ($25).
  • Fees are subject to change at any time without notice.

Payments

  • Payment in full is required at the time services are rendered for charges that are your responsibility. “Your part” varies depending upon your insurance plan.
  • Cash and credit cards are accepted forms of payment. A credit card on file is required to book some appointments, but is not charged unless there is a violation of our cancellation policy. In some instances, a deposit must be collected to reserve your appointment. You will be notified beforehand if this is the case.
  • HSA/FSA. Health spending (HSA) and flex spending (FSA) accounts are accepted for all medically necessary services.
  • Square, Quickbooks and Other Credit Card Processing. We use Square for online payment, analytics, and other business services. Square collects identifying information about the devices that connect to its services. Square uses this information to operate and improve the services it provides to us, including for fraud detection. You can learn more about Square and read their privacy policy at https://squareup.com/help/us/en/article/3796-privacy-and-security. We utilize Quickbooks Merchant Services for in-office charges. Their privacy policies can be accessed via the following links https://quickbooks.intuit.com/payments/legal/.

Cosmetic/ Aesthetician/ Elective Procedures

  • These services are billed under a separate fee schedule. As always, payment is due at the time of service. Some procedures may require a deposit before services are rendered. We will not charge your card without first discussing your charges with you.

Lab and Pathology Fees

  • We have negotiated discounted fees for pathology, approximately $55/specimen, or you may choose to get pathology billed through your health insurance.
  • Any service(s) provided by a lab or hospital is a contract between you and that lab or hospital should be handled with that lab or hospital. It is not the responsibility of our practice.
  • It is your responsibility to know which procedures your insurance will and will not cover at these facilities and to request an Explanation of Benefits (EOB) from your insurance carrier.

No-show and Cancellation Fee.

  • We require a 24-hour notice for cancellation. Kindly follow the instructions for cancellations for our online scheduling system or call us to cancel/reschedule as necessary. Missed visits without 24-hour notice will result in a charge of $100.00 fee.
  • At the time of scheduling some select appointments, we will require a credit card to be on file via our secure Square or other credit card processing company. You will be notified at the time of booking if your appointment requires a credit card on file.
  • The credit card required for booking will NOT be charged unless there is a no-show or cancellation in less than 24 hours. Your office visit fee will be charged upon arrival at your appointment at Galt Dermatology.
  • Exceptions to the cancellation policy are made for emergencies and decided on a case-by-case basis at the discretion of Galt Dermatology.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

We are required by law to provide you with this notice that explains our privacy practices concerning your medical information. This notice describes how we may use and disclose your protected health information for treatment, payment, and health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your protected health information, and we also describe them in this notice.

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

The following paragraphs describe the different ways that we use and disclose your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health information fall within one of these categories.

Treatment. We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related service. We will also disclose your health information to other physicians who may be treating you. Additionally, we may, from time to time, disclose your health information to another physician whom we have requested to be involved in your care. For example - we would disclose your health information to a specialist to whom we have referred you for a diagnosis to help in your treatment.

Payment. We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example - we may include information with a bill to a third-party payer that identified you, your diagnosis, procedures performed, and supplies used in rendering the service.

Health Care Operations. We will use and disclose your protected health information to support the business activities of our practice. For example, - we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff's performance while caring for you. Also, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for our practice.

Other ways we made use and disclose your protected health formation:

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, a close friend, or any other person you identify that is involved in your medical care or payment for care.

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 establish 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 illness.

Inmates. We will use 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.

If you wish to inspect or copy your medical information, you must submit your request by writing to our office: practices of Galt Dermatology, PLLC, and Peter L. Babinski, M.D., PA, 800 East Broward Blvd, Suite 103, Fort Lauderdale, FL 33301. You may mail in your request or bring it to the office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.

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 that 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 of 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 my 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 cost 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.

To file a complaint with our manager, you must make it in writing within 180 days of the suspected violation. Provide as much detail as you can about the suspected violation and send it to the offices of Galt Dermatology, PLLC, and Peter L. Babinski MD, PA at 800 East Broward Blvd, Suite 103, Fort Lauderdale, FL 33301. You should know that there would be no retaliation for filing a complaint.

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.

For More Information

If you have questions or would like additional information, you may contact our office at (954) 463-5406.

Effective Date: April 14, 2003.

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