Siloam Springs Office
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Responsible Party(If different than patient)
Policies and Consents
**Medical Photography Consent: Medical photographs may be taken and stored in patients’ electronic medical
chart. **HIPAA Consent Policy: With my consent, Ozark Dermatology Clinic (ODC) may use and disclose my
protected health information to carry out treatment, payment and healthcare operations (TPO). I understand that I
have the right to review ODC's Notice of Privacy Practices and have been given the opportunity to do so. With my consent, ODC may call my house or other designated locations and leave a message on voice mail or in person in
reference to any items that assist the practice in carrying out TPO, such as appointment reminders, lab results and insurance information among others.
Payment and Insurance Policy: To avoid a $35 fee, a 24 hour cancellation notice is required.
Payment is due upon completion of today's office visit. If you have insurance, we will be happy to process your
claim, but we request that you pay your estimated portion at the time of service. This includes any co-pays,
percentages and deductibles. We require that all insurance payments are hereby assigned to Ozark Dermatology
Clinic for services rendered to the patient or dependent. Charges denied due to insurance policy limitations will be transferred to the patient or guarantor. Payment for any treatment deemed by insurance companies to be cosmetic or
not medically necessary is the responsibility of the patient. FAILURE TO KEEP SURGERY APPOINTMENTS
WILL RESULT IN TERMINATION OF CARE FROM OZARK DERMATOLOGY CLINIC.