Information Center

Skin Cancer Foundation

National Cancer Institute

National Psoriasis Foundation

National Eczema Association

American Academy of Dermatology

American Board of Dermatology

American Society of Plastic Surgeons

American College of Mohs Micrographic Surgery and Cutaneous Oncology

AARP through United Healthcare

AARP Supplement to Medicare

Aetna

Anthem/Blue Cross Blue Shield

Caresource of Kentucky Marketplace

Caresource of Indiana Marketplace

CenterCare

ChampVA

Cigna

Encore Health Network

Essence

First Health

Gateway Medicare Advantage

HealthSmart

Humana

Medicare

PHCS/Multiplan (GEHA)

Railroad Medicare

Signature Advantage

Tricare (referral required before scheduling)

Triwest (referral required before scheduling)

United Healthcare

Veterans Administration (referral required before scheduling)

Wellcare Medicare

Wellcare Medicaid

Wellcare Ambetter Commercial Plan

We only accept Wellcare Medicaid

Financial Policies

– It is your responsibility to understand your insurance benefits. Insurance coverage is not a guarantee of payment for services provided.


– Proof of insurance (insurance card) is required at the time of the service if you would like insurance to be billed for all or part of your services. If proof of insurance is not available you will be required to pay for your services in full at the time of the visit.


– Payment for services performed is the responsibility of the patient. Any portion of the charges not covered by the patient’s insurance carrier must be paid by the patient. This “patient portion” is due at the time of your visit if you have a co-pay and/or deductible associated with your insurance plan.


– Co-payments are due in full at the time of the appointment. If you are unable to pay your co-pay, you must reschedule. Because dermatologists are considered specialists by most insurance carriers, co-payments are generally higher than a primary care physician.


– For patients with High-Deductible Healthcare Plans (HDHP) who have not yet met their annual deductible, all or a portion of the cost of the rendered services shall be collected at checkout.


– If your insurance plan has a deductible, please come to your visit prepared to pay for your services. Many insurance carriers consider dermatologic procedures “surgical” procedures and therefore different from an office visit.


– If it is discovered after we submit your insurance claim that you have met your deductible, or that your negotiated insurance rate is less than collected, a refund will be issued.


– For high-cost procedures (like MOHS Surgery), a minimum of $700 to $3,000 is due at the time of the procedure.


– For procedures that are considered cosmetic and not commonly covered by insurance plans (skin tag removal, botox injections, etc.), full payment is due at the time of service.


Referral Policy – Some insurance carriers require referrals from a primary care provider in order to be seen by a specialist. If your insurance carrier requires a referral, we must have a valid referral prior to scheduling your appointment.


– We accept all major credit cards, checks or cash.

Please notify the office as soon as possible if you are not able to make your appointment. Any patient cancelling an appointment without a 48-hour notice or who misses their appointment without a phone call shall be required to pay a $50 no show fee.

PATIENT FORMS 2025

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PHI CONSENT FORM

The Skin Group, PLLC

Protected Health Information Disclosure, Consent to Leave Messages and Emergency Contact

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Emergency Contact

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Notice of Privacy Practices ACKNOWLEDGEMENT of RECEIPT of PRIVACY NOTICE and Consent for Use or Disclosure of Patient Information for Purposes of Treatment, Payment and Healthcare Operations

Our office respects the privacy of personal information and understands the importance of keeping this information confidential and secure. This Notice describes our privacy practices with respect to your health information. Our privacy practices apply to current and former patients.

Types of Personal and Health Information We Collect

We collect a variety of personal and health information when delivering health care. You provide some of this information, when you initially come into the office (such as address, Social Security number, and health history). We also receive additional personal and health information (such as eligibility) through our transaction with employers, insurance companies and other health care providers. We limit the collection of personal information to that which is necessary to administer our business, provide quality service, and meet regulatory requirements.

How We Protect Personal and Health Information

We treat personal and health information securely and confidentially. We limit access to personal information to only those persons who need to know that information to provide services to patients (for example, our billing personnel and medical assistants). These persons are trained on the importance of safeguarding this information and must comply with our procedures and applicable law. We meet physical, electronic, and procedural security standards to protect personal and health information and maintain internal procedures to promote the integrity and accuracy of that information.

Disclosure of Personal and Health Information

We may share any of the personal and health information we collect (as described above) with our associates as permitted by law. We may also disclose this information to non-associated entities or individuals as permitted or required by law. Non-associates with whom we may disclose information as permitted by law include our attorneys, accountants and auditors, collection agencies, a patient's authorized representative, other health care providers, public health authorities, coroners, medical examiners, funeral directors, and organ donation organizations, Institutional Review Boards for research purposes, third party administrators, insurers, and law enforcement or regulatory authorities. We may also disclose any of the personal and health information we collect in order to provide appointment reminders or to give you information about other treatments or health-related benefits and services that may be of interest to you. In addition, in the event that this practice is sold or merged with another office, your personal and health information will become the property of the new owner. We do not disclose personal or health information to any other third parties without a patient's request or authorization.

You may request restrictions on certain uses and disclosures of your personal and health information. Your restriction request should be submitted in writing. According to HIPAA regulation, we are not required to agree with a requested restriction.

Individual Rights to Access & Correct Personal Health Information

We have procedures for a patient to access the personal and health information we collect, and other information we collect in connection with, or in anticipation of, a lawsuit or legal claim, we will make this information available to the patient upon written request.

Our goal is to keep our patient’s information up-to-date and to correct inaccurate information. We have procedures in place to ensure the integrity of our information and for the timely correction of incorrect information. If you believe that any personal or health information we have about you is not accurate, please let us know by contacting our Privacy Officer at 502-583-6647.

Further Information

The practice reserves the right to amend this Notice of Privacy Practices at any time in the future. Until such amendment is made, the practice is required by law to comply with this Notice.

Patient Portal

Prior to or the day of your office visit, we will make your medical chart available to you via our patient portal which is accessible via www.skingroup.org. This patient portal is maintained by our EMR vendor. This portal will allow you to view your clinical summary from your office visits as well as additional information regarding your care. If you have questions or issues with using your portal account, please contact us at 502-583-6647.

I hereby consent to the practice using or disclosing my personal and health information for the reasons listed above. I further acknowledge the practice has provided me a copy of its Notice of Privacy Practices, which provides a detailed description of the uses and disclosures allowed by this consent, as well as other rights I have regarding my personal and health information.
By signing here you verify the information above is completed accurately to the best of your knowledge.
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FINANCIAL POLICY

PLEASE READ THE FOLLOWING INFORMATION CAREFULLY

Thank you for choosing The Skin Group as your healthcare provider. Our primary mission is to provide our patients with outstanding medical care. Your clear understanding of our Financial Policy is important to our professional relationship. This financial policy is applicable to all services offered including but not limited to Dermatology/MOHS Micrographic Surgery, Telehealth and Aesthetic appointments.

YOUR INSURANCE BENEFIT IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE PLAN. IT IS YOUR RESPONSIBILITY TO VERIFY NETWORK PARTICIPATION OF THE SKIN GROUP OR ANY PROVIDER OF THE SKIN GROUP WITH YOUR INSURANCE CARRIER.

Benefits/Coverage:

We wish to stress that, while we are happy to submit insurance claims on your behalf, financial responsibility for services rendered rests with the patient regardless of the nature or extent of any insurance coverage. It is your responsibility to understand your insurance benefits. Insurance coverage is not a guarantee of payment for services provided. Intentional misrepresentation of insurance information is considered fraud and may be prosecuted under the laws of this state.

Your insurance plan may require information directly from you. Your failure to timely comply with your insurance plans request may result in your claim being denied and if so, will result in our seeking full reimbursement from you for services rendered.

Any portion of the insurance carrier’s allowable rate for services performed that is NOT paid by the carrier is the responsibility of the patient.

Non-Covered Benefits:

Please be aware of some or all of the services you receive may not be covered by your insurance plan. Any portion of the insurance carrier’s allowable rate for services performed that is NOT paid by the carrier is the responsibility of the patient. Any remaining balance for non-covered benefits, deductibles and co-insurance are your responsibility and payment for any patient responsibility is due at check-in and/or check-out on the day of your appointment.

For ALL AESTHETIC procedures (i.e. skin tag removal, fillers, products, etc.) which are not covered by insurance plans, full payment is due at the time of service. In addition there are no refunds on any aesthetic procedures or products. You will receive an “in-store” credit on your account to be used for an aesthetic procedure or product in the future. Aesthetic money cannot be used toward any medical procedure or product.

Proof of Insurance:

Proof of insurance (Insurance ID Card) is required at the time of service if you would like insurance to be billed for your visit.

All patients must complete or update demographic information before seeing the provider. This form will cover any changes in address, employment, insurance, etc. However, it is your responsibility to ensure we have your correct information and an up-to-date copy of your insurance card(s) in a timely manner.

If proof of insurance is not available or any other updated information is not provided at the time of your visit, you will be required to pay for your services in full at the time of your visit or reschedule your appointment.

If you do not have insurance, payment in full is expected at the time of your visit.

Copayments, Deductibles, and Past Due Balances

Many insurance plans include co-payments and deductibles. Co-payments, deductibles and past due balances are due prior to being seen by any provider. Payment is part of your contract agreement with your insurance plan and cannot be waived.

If your plan is a deductible plan, The Skin Group will collect $125 for a new patient, $100 for an established patient and/or a full deductible payment for MOHS surgery at check-in.

If any payment is not collected your appointment will be required to be rescheduled until the payment is paid in full.

Past due balances are due upon receipt of a statement or before or at the time of a scheduled appointment, whichever comes first. If you are unable to make payment at the time of the scheduled appointment, your appointment will be rescheduled for another day that is convenient for you.

We accept cash, personal checks, Visa, Mastercard, Discover, American Express or money orders as payment for services rendered. All credit card transactions shall be assessed a surcharge. This surcharge does not apply to cash, checks or debit card transactions.

A returned check fee of $50.00 will be assessed to your account for any returned checks.

Referrals/Authorizatons:

Some insurance plans require a referral from your primary care physician to obtain services of a specialist. These health plans will not pay for services rendered without a referral. It is your responsibility to obtain the referral prior to your appointment. This would include any dermatology appointment or MOHS surgery.

Some insurance plans require an authorization. Obtaining a prior authorization for services is not a guarantee of payment of benefits. A prior authorization means that the information given at the time meets the medical necessity for the services but is not a guarantee of payment. Your insurance plan will confirm to you that even though the services may be authorized, the services may not be covered under your plan and a decision of payment will not be rendered until the claim is submitted.

Billing:

The Skin Group bills insurance as a courtesy to our patients.

Your bill might include office visits, destructive treatments, biopsies, injections and removal of benign/malignant lesions, pathology or other charges. Medical insurance usually does not cover the entire cost of medical care, specific procedures and/or certain office visits.

Once you have paid your patient responsibility on the appointment day and/or once insurance has processed your claim and if there remains a patient balance due, you will receive a statement. If you have overpaid your patient responsibility we will remit a check or refund you for the overpayment.

Please be aware that if there is a balance that remains unpaid, we reserve the right to turn your account over to a collection agency for all balances 90 days past due. If an account is referred to outside collections, we reserve the right to dismiss the patient from the practice. The account is subject to additional fees incurred by the practice and/or related to the collections activity. Pursuant to Kentucky Revised Statutes (KRS 411.195), if your account requires the practice to use an attorney to recover the amount you owe, either by legal action or by other means, you will be responsible for payment of the practice’s reasonable attorney fees and court costs.

You may also receive a separate bill from outside pathology and laboratory clinics that are utilized by The Skin Group and are separate from your physician’s fee. IT IS YOUR RESPONSIBILITY TO ENSURE THAT THE PATHOLOGY OR LABORATORY CLINICS ARE IN NETWORK WITH YOUR INSURANCE POLICY.

The parent/guardian that signs this Financial Policy will be responsible for payment on the minor’s account, regardless of who is the primary policy holder of the insurance

Billing:

+ If at any time you provide a wireless telephone number or email address at which you may be contacted, you consent to receive calls or text messages including but not restricted to communications regarding billing and payment for items and services, unless you notify the Practice to the contrary in writing.

+ Phone calls or text messages include but is not restricted to pre-recorded messages, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication from the The Skin Group, affiliates, contractors, servicers, clinical providers, attorney or its agents including collection agencies.

+ If at any time you provide an email address at which you may be contacted, unless you notify the Practice to the contrary in writing, you consent to receiving medical instructions, statements, bills, marketing material for new services and payment receipt at that email address.

Wireless Telephone Calls and Email Usage:

If at any time you provide a wireless telephone number or email address at which you may be contacted, you consent to receive calls, text messages, and emails including but not restricted to communications regarding billing and payment for items and services, receiving medical instructions and marketing materials unless you notify the Practice to the contrary in writing.

Phone calls, text messages, and emails include but are not restricted to pre-recorded messages, artificial voice messages, automatic telephone dialing devices or other computer assisted technology, or by electronic mail, text messaging or by any other form of electronic communication from the The Skin Group, affiliates, contractors, servicers, clinical providers, attorney or its agents including collection agencies.

No Show Fees and Missed Appointments:

We respect our patients’ time and make every attempt to stay on schedule. Please understand that delays and emergencies sometimes occur but that we value your time and are doing everything we can to make your visit as efficient as possible.

All patients are required to arrive ten (10) minutes prior to their appointment time. If this policy is not followed your appointment may need to be rescheduled.

All appointments not cancelled 48 hours prior to your scheduled appointment, or a no-show appointment will be charged a $50.00 fee which is non-refundable. Repeat missed appointments may result in a discharge from the practice.

Agreement

I have read and understand the above information. I authorize the release of any medical or other information necessary to process my insurance claim. I authorize payment of medical benefits from my insurer, including Medicare, directly to The Skin Group. By signing this form, I am accepting financial responsibility for payment of medical or aesthetic services provided by The Skin Group and other medical facilities for services that are necessary for my diagnosis or treatment regardless of treatment outcomes. I acknowledge that insurance billing services provided by The Skin Group is a courtesy and does not relieve me of financial responsibility for services provided. This assignment of benefit shall remain in effect as long as I receive treatment from The Skin Group.
By signing here you verify the information above is completed accurately to the best of your knowledge.
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