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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.

All consultation fees, follow-up appointment fees, deposits, and procedures done at SkinLab are considered services rendered, and thus, are non-refundable.

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.