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MEDICAL HISTORY

NOTICE OF PRIVACY PRACTICES CONSENT

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The Patient Understands That:

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Authorization, Assignment And Acknowledgment

My signature below indicates that I have read and understand this consent in its entirety, that my questions have been adequately answered, and that a copy of the Notice of Privacy Practices is available to me upon my request.

FINANCIAL POLICY AT NICHOLSMD

Financial Policy

Payment is due in full at the time of service for consultations, examinations, and procedures. We accept cash, checks, and all major credit cards. As a courtesy, we also offer Care Credit™, a credit card financing program for medical and cosmetic procedures. Please ask for more information if you are interested.

All sales, fees, deposits, and procedures done at NicholsMD of Greenwich are final and non-refundable. Failure to use products or treatments does not constitute a basis for refusing to pay any of the associated charges. Laboratory and Pathology Services will bill you and/or your insurance plan directly for laboratory services rendered (blood work, cultures, biopsy specimens, etc.).



Dr. Nichols and NicholsMD of Greenwich are considered out-of-network providers for all insurance plans. Therefore, payment is due in full at the time of service. As a courtesy, we would be happy to print or email your itemized superbill to you, so you can submit it to your insurance company. If your insurance company accepts out-of-network services, they will reimburse you according to their policy. It is your responsibility to know your insurance company’s out-of-network policies.



Our office will keep your credit card on file in order to expedite checkout transactions, charge non-refundable deposits towards specific appointments, and/or cancellation etiquette breaches. If you change your payment method after we have completed your transaction, there will be a 3% charge back fee. There is a bounced check fee of $45. The credit card number is kept in a secure program in our system.


For follow-up visits, defined as an appointment when a treatment is not administered, there is a physician fee of $225, or other provider fee (PA/APRN) of $195. This office fee is waived if a treatment is administered or pre-purchased at that one visit.



All consultation fees, follow-up appointment fees, deposits, and procedures done at NicholsMD are considered services rendered, and thus, are non-refundable. All product sales are final and cannot be returned or exchanged.

Cancellation Etiquette
NicholsMD of Greenwich has a 24-hour cancellation policy. All appointments canceled less than 24 hours prior to the appointment will be charged $175. We also require non-refundable deposits for specific treatments and Saturday appointments.


My signature below indicates that I am fully aware of the financial and cancellation policies of NicholsMD of Greenwich. And I accept full responsibility for all expenses incurred. In addition, I grant authorization to release any information required to obtain payment of medical benefits. I have read and understand this statement in its entirety and my questions have been adequately answered.

Authorization, Assignment and Acknowledgment
By signing this document you have been made aware and agree to our financial and cancellation policies.