Intake Form

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    HIPAA Patient Privacy Acknowledgment and Consent

    I understand that Reisenauer Dermatology, LLC, and Hawaii Dermatopathology, LLC (referred to below as “This Practice”) will use and disclose health information about me. I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information. I understand and agree that This Practice may use and disclose my health information in order to:
    • make decisions about and plan for my care and treatment;
    • refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
    • determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care;
    • perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.
    I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information. I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice’s Notice of Privacy Practices in effect will be posted in the waiting/reception area. I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

    I acknowledge and that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.


    Financial Consent Form and Form Submission

    In order to establish optimal relations with our patients and avoid misunderstandings, our staff is trained to consistently inform you of our financial payment policies. Payment is required for all services at the time they are rendered unless you are insured with a plan in which we participate. Our staff will make a good faith effort to pre-verify your coverage. For those insured patients, applicable co-payments, co-insurance and/or deductibles will be collected at the time of service. We accept payment in the form of credit card only. If you have medical insurance, we will help you to understand your benefits. However, it is your responsibility to understand the benefits your insurance has for you. All self pay patients (which include those patients receiving cosmetic services) are required to pay in full at the time of service. For cosmetic appointments, a $50 deposit is required at the time of scheduling the appointment. This deposit is non-refundable in the case of a no show. If a biopsy or other surgical procedure is performed specimens are sent for processing and/or analysis to an outside laboratory. This may result in a separate bill and a charge to your account. Likewise any other blood or laboratory test done outside the premises of Reisenauer Dermatology may also result in a separate bill and a charge to your account. In the event that your account must be turned over to a collection agency, a 30% collection fee as well as a $30 returned check fee (when applicable) will be added to your account balance.

    Cancellation Policy

    Our office strives to provide you with exceptional medical care provided in a warm, professional environment. In order to ensure timely scheduling for all patients, we request 24 hours notice to cancel an appointment. If you fail to show up for an appointment without notice, we will not charge you the first time. However, if this occurs more than once you will be responsible for a cancellation fee of $50. If you fail to show up for a third appointment, we will require a $50 deposit to schedule a subsequent appointment. For surgery appointments, 48 hours notice is required to cancel an appointment.








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