Patient Forms

Patient Resources

New Patient / Registration Forms

All of the forms provided are in Adobe PDF format. If you need to install a free copy of Adobe Reader, click here.

 
 

Our Office Policies

 

Equal Opportunity

Thank you for entrusting us with your health care. As we hope you are already discovering from our gracious setting and inviting, knowledgeable staff, all of us at Arsenault Dermatology are sincerely committed to providing you excellent care. We value all of our patients and look forward to doing everything possible to ensure you have a wonderful experience.

Please read and initial all of the following policies. These office policies are designed to clearly communicate our services. Our office is exceptionally efficient and we strive to ensure that all of our patients have an equal opportunity to receive the best service possible.

 

HIPAA – Health Information Portability and Accountability Act

We protect your privacy in every way possible. Our office strictly adheres to the HIPAA law. All employees are fully trained on HIPAA guidelines and all of our office technology is carefully designed to provide maximum protection of your personal information. We never share your information with anyone not directly involved with your care, insurance or billing without your consent.

All patients must complete and sign our HIPAA policy form. All patients are also requested to present their photo ID at each visit. These are HIPAA requirements specifically designed to protect your identity from misuse. Please refer to our “Notice of Privacy Practices” posted in the lobby and on our website.

 

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.

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.

 

Minors

All minors must be accompanied by a parent or legal guardian on their first visit. After the first visit, a waiver can be signed to allow us to continue active treatment for the minor without the parent/legal guardian present at future visits. If you are interested, please ask our staff for more information.

 

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:

For All Patients

 

Option 1 – Medicare

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

 

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

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

 

Option 3 – Self-Pay Policy

Dr. Arsenault extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of her self-pay patients. Arsenault Dermatology Self-Pay Policy requires self-pay patients to pay $100 upon check-in.

At the end of the visit:

Self-pay patients may be eligible for discounted rates with local pathology laboratories.

 

Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Effective Date: September 8th, 2016

 

Your Rights

You have the right to:

 

Your Choices

You have some choices in the way that we use and share information as we:

 

Our Uses and Disclosures

We may use and share your information as we:

 

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

Ask us to correct your medical record

Request confidential communications

Ask us to limit what we use or share

Get a list of those with whom we’ve shared information

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

File a complaint if you feel your rights are violated

 

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

In the case of fundraising:

 

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

Example: We use health information about you to manage your treatment and services.

Bill for your services

Example: We give information about you to your health insurance plan so it will pay for your services.

 

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Help with public health and safety issues

We can share health information about you for certain situations such as:

Do research

Comply with the law

Respond to organ and tissue donation requests

Work with a medical examiner or funeral director

 

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

Respond to lawsuits and legal actions

 

Our Responsibilities

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

 

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

 

Contact Us

For further questions or concerns regarding this notification please contact the office. If you have an issue to report please submit in writing to one or both of the following individuals. Please make sure to include details of any incident and your contact information for follow up.

Privacy Officer and Practice Manager

Eva Fekete
Arsenault Dermatology
8926 77th Terrace East, Suite 101
Lakewood Ranch South, FL 34202
Email: eva@arsenaultdermatology.com

Security Officer/COO/CTO

Mike Arsenault, MD, MBA
Arsenault Dermatology
8926 77th Terrace East, Suite 101
Lakewood Ranch South, FL 34202
Email: DrMike@ArsenaultDermatology.com