Dermatology of Seattle

13610 First Avenue South, Seattle, WA 98168

206-248-5020 – 206-244-8425 (fax)

INFORMED CONSENT / AGREEMENT TO PAY

PATIENT NAME: _______________________________________________________

DATE OF SERVICE: _____/_____/_____ PROVIDER: ________________________

TYPE OF SERVICE: _____________________________________________________

ESTIMATED OR EXACT COST: ___________________________________________

There is no referral/authorization on file for today’s services:

_____ Your primary care provider (PCP) has been contacted and will not approve these services.

_____ Your PCP or Specialist has initiated a referral/authorization but we have not received a hard copy from your insurance company.

_____ The referral/authorization on file has expired, approved number of visits have been used or today’s specific services are not included.

Please contact your PCP or Specialist regarding your referral/authorization. Most insurance companies will not honor retroactive referrals/authorizations. This agreement is void upon receipt of a hard copy authorization from your insurance company.

_____ The service(s) is not a covered benefit under your health plan.

_____ Proof of insurance (insurance card or letter from employer/insurance plan) was not presented or unavailable at the time of service. Patient was informed that their insurance carrier (including governmental agencies) will not be responsible for payment of the service(s) listed above unless proof of insurance is received within 14 days from today’s service.

_____ The service(s) is not covered under Medicaid.

_________________________________________ _____/_____/_____

Patient or Guarantor Date

_________________________________________ _____/_____/_____

Dermatology of Seattle Representative Date