Consent for Treatment & Photography

I hereby consent to such diagnostic procedures and treatments including physiological, psychological and behavioral health services, which in the judgment of my healthcare provider may be considered necessary or advisable. I acknowledge that Healthcare Colleagues PA and its affiliated clinics, including but not limited to its fictitious name Altamonte Dermatology (collectively referred to hereinafter as the 'Practice'), and its physicians, advanced practice providers (APPs), and staff perform health care teaching and research; therefore, my treatment and care may be observed and aided by students and residents under appropriate supervision. I consent to the Practice taking photographs of me for treatment purposes, and I consent to the use of such photographs and my medical data for educational purposes. I authorize the Practice to retain, use for scientific/research purposes, or appropriately dispose of any tissue specimens taken from my body. Furthermore, pursuant to Florida law, I acknowledge I have been informed of the licensure of the practitioners at this office (e.g., MD, DO, NP, PA), and by proceeding with my visit, I indicate my choice and consent to be treated by my scheduled practitioner.

Privacy Acknowledgment and TPO Authorization

I acknowledge that I have been provided with the practice's Notice of Privacy Practices (NOPP). I authorize the practice to use and disclose my health information for Treatment, Payment, and Healthcare Operations (TPO) as described in the NOPP. This authorization specifically includes the use and disclosure of substance use disorder (SUD) records (if any) received from other providers for TPO purposes, subject to the strict legal proceeding restrictions described in the NOPP. To prevent adverse drug interactions, I authorize my provider to query and review my medication fill history.

Financial Responsibility & Assignment of Benefits

Assignment of Benefits: I hereby assign to the practice payment from all third-party payors (including Medicare, Medicaid, Tri-care, worker's compensation, auto insurance, and sponsors) for past, present, or future services.

Patient Responsibility: I agree to be personally responsible for payment of any healthcare services not covered by third-party payors, including deductibles, co-insurance, out-of-network services, and co-payments, payable at the time of my visit. If the insurance information I have provided is not active at the time of service or if the services provided are not covered by my insurance plan, I will be responsible for any balance due.

Billing & Collections: The practice bills insurance as a courtesy but reserves the right to demand full payment at any time prior to third-party payment. If an account is sent to collections, I agree to pay all associated attorney's fees, court costs, and collection agency fees, and I specifically waive any wage garnishment exemptions if a judgment is entered against me.

Outside Services: I understand I may receive separate bills from unaffiliated third-party organizations for laboratory, imaging, and pathology services, for which I am financially responsible.

Overpayment Refunds: In the event of a patient overpayment, the practice processes and issues refunds in accordance with applicable state and federal laws. Please note that our billing office determines and verifies an overpayment has occurred only after all relevant insurance claims have been fully adjudicated and reconciled. To expedite this process, refunds will be automatically issued to the credit card used to make the payment. If the card becomes inactive, a paper check will be mailed. It is your responsibility to keep your current address on file to facilitate the timely receipt of any refunds due.

Deposits, No-Shows, and Late Cancellations: The practice utilizes deposits for certain procedures and enforces policies regarding missed appointments (no-shows) and late cancellations. We reserve the right to implement these fees. You will be explicitly notified of any applicable deposit requirements or specific cancellation fees at the time you schedule your appointment.

Liens: If my treatment is due to an accident or injury, the practice shall have a lien upon the proceeds of any cause of action or settlement accruing to me to recover payment for health care services.