New Patients

Mission Statement

Our practice is working together to realize a shared vision of uncompromising excellence in dermatology.

To fulfill this mission, we are committed to:

• Listening to those we are privileged to serve.
• Earn the trust and respect of patients, profession and community.
• Exceed your expectations.
• Ensure a creative, challenging and compassionate professional environment.
• Strive for continuous improvement at all levels.

Patient Forms

• Patient Information Form
• Physical History Form
• Acknowledgement of Notice of Privacy Practices

Cancellation Policy

We strive to provide exceptional medical care in a timely manner. Our staff understands your time is precious and that changes may occur with little notice. To efficiently serve all of our patients we require a 24-hour notice for all cancellations. This provides us enough time to offer your valuable appointment time to another patient. Late arrivals may be asked to reschedule.

Appointments cancelled with less than 24-hours notice may be charged a cancellation fee.

• Surgery / Cosmetic visit $100
• Skin check / Focused visit $25

As a courtesy to you, the first no-show fee may be waived based on circumstances. It is our strong desire to create a lasting relationship built on mutual respect. We do everything we can to accommodate your schedule and we thank you in advance for your cooperation.

Prescription Refills

Please allow us up to two days to process your refill request. Most refills are generally completed within one business day. To maintain the highest clinical standards, we require at least an annual exam for prescription refills. Your provider may require more frequent visits depending upon the medical condition.

The fastest way to obtain your refill is for your pharmacist to directly fax/email the request.

Prescription refills are a routine procedure and we gladly perform them during normal business hours. Any refill requests made after-hours (ie. on the emergency line) may incur an additional fee.

Financial Policy

We adhere to a clear and comprehensive financial policy. As a courtesy to all of our patients, it is our normal practice to:

• Verify eligibility and benefits prior to your appointment.
• File your claim with Medicare and/or commercial healthcare insurance providers.

For All Patients

• Payment is required at the time of service unless prior arrangements have been made.
• I am responsible for knowing the terms of my policy, including deductibles, copayments, coinsurances and any applicable referral procedures.
• I am financially responsible for all charges, whether or not covered by insurance. This includes, but not limited to, out-of-network and cosmetic service charges. 9 All pathology and/or laboratory fees are billed independently of Burnett Dermatology and are ultimately my responsibility.
• Burnett Dermatology’s billing department will contact patients with overdue accounts. Every effort is made to help our patients satisfy their obligations in a reasonable manner.
• In the event we are unable to verify your benefits or you cannot provide proof of coverage at the time of visit, I can either:

• Reschedule my appointment, or
• Make payment in full. We will provide financial statements to help you pursue reimbursement of the claim (upon request).

Option 1 – Medicare

My initial here and full signature below indicates that I hereby:

• Authorize Burnett Dermatology to release all information necessary to process my claims to CMS and its agents.
• Assign any insurance payments (both Medicare and Medigap insurances) to be paid directly to Burnett Dermatology.
• Understand this Assignment will remain in effect until revoked by me in writing. I also understand that:
• All Medicare beneficiaries without Medigap (ie. secondary insurance) coverage are responsible for paying the required 20% copayment at the time of service.

Option 2 – Commercial Insurances (ie. PPO, HSA)

Burnett Dermatology will release all information necessary to process my claims to my insurance company and its agents

• Assign any insurance payments (both primary and secondary insurances) to be paid directly to Burnett Dermatology Understand this Assignment will remain in effect until revoked by me in writing. I also understand that:

• My healthcare insurance is a contract between my insurer and me.
• It is my responsibility to verify benefits for my particular plan and to make certain all proper authorizations have been obtained.
• If I do not obtain the necessary referral I understand that I am solely responsible for all costs of the services provided.
• It is my responsibility to satisfy any outstanding balances at the time of service, including: annual deductibles, copayments, out-of-network costs and/or coinsurances.

Option 3 – Self-Pay Policy

We offer a self pay discount to uninsured patients.