Health History Form
We accept a wide variety of insurance plans. For those without insurance, we offer reduced pricing that reflects our administrative savings for time-of-service payment. Please call our office to verify insurance eligibility. You may also call the number on your insurance card to verify that Miller Family Dermatology is a covered provider.
We require that you have a valid credit card or HSA card on file with our office for payment of your balance after insurance processes. Co-payments can be paid at the time of your visit with the payment method of your choice (cash, check, Visa, Mastercard or Discover) or with the card on file. In no circumstances can we waive co-payments. Services that insurance does not cover, such as cosmetic procedures including Botox, fillers, chemical peels and cosmetic removals, require payment at the time of service.
We are an in-network provider for almost all major insurance plans. These companies include:
Fill our your Health History form (under the For Patients tab) before your appointment (preferably at least a day before) so that we can have your health history entered before you arrive. If you prefer to complete it in person, please arrive 15 minutes before your scheduled check-in time.
The last forms to complete are the Financial and Privacy Policies Acknowledgement and the Credit Card On File form. These forms just require simple signatures, which we will obtain when you check in. However, you may review the policies using the Financial Policies, Credit Card On File and HIPAA Notice buttons below.
Bring with you:
Review our map so you can find our location.
Keep our phone number handy in case you get lost. It's (425) 654-1275.
Schedule an appointment by calling 425-654-1275 or by requesting an appointment on our website, www.millerfamilydermatology.com. If you are having an urgent problem, please call to schedule your appointment so that we can get enough information about your situation and find the best solution.
Fill out your paperwork before your appointment. To make this easier, we have made our our Health History form available on our website, www.millerfamilydermatology.com. Before we can begin your appointment, all your information needs to be entered into our electronic medical record. When you come in, we will need to take a copy of your insurance card and photo ID and swipe the credit or HSA card you wish to keep on file, and we will need you to review and sign our privacy and financial policies. Once all your information is entered into our electronic medical record, your forms are signed, your cards are scanned and your copay is collected, you will be considered “checked in.” If you have not filled out your paperwork in advance, please arrive at least 25 minutes before your scheduled appointment.
Your appointment time is the time you are scheduled to be seen. You must arrive early to process your copay. Patients who are on time (checked in by their appointment time) are seen at their appointment time. Patients who have checked in on time will be seen ahead of those who check in late. If you arrive late, we may need to abbreviate or reschedule your visit.
Call ahead if you are running late for your appointment time. We will do all that we can to accommodate your appointment and to minimize the need to reschedule your appointment.
No shows and cancellations with less than two full business day’s notice are a significant problem for our small practice. Many practices overbook on purpose so that no-shows and cancellations won’t limit access for other patients as well as cause a financial hardship for the practice.
When it comes to no shows and cancellations, we have two choices:
1. A strict policy; or
2. Overbooking (leading to long wait times at our office).
We respect your time, and don’t want to keep you waiting for your appointment. We feel the strict policy is the best fit for our practice and we are proud of our ability to run on time.
If you need to cancel or reschedule your appointment, let us know at least two full business day before your appointment. For example, if you have to cancel an appointment on Monday at 9 am, we need to know by the previous Thursday at 9 am. This allows us to offer the appointment to another patient on our short-notice cancellation list. A $50 charge will be assessed for no-shows or cancellations with less than two full business day’s notice.
Miller Family Dermatology reserves the right to dismiss patients for violating this policy. Violations include:
1. Not showing for scheduled appointments
2. Cancelling appointments with less than two full business day’s notice
Important Information to Parents and Guardians of Minor Children
The providers and staff of Miller Family Dermatology place great emphasis on the health and well being of each and every patient in our clinic and we appreciate that you have entrusted us to provide health care services to your minor child. We look forward to working with you to ensure that your child receives the best health care possible.
As a general rule, we require the consent of a parent or legal guardian in order to provide health care services to a minor child (an unmarried person under the age of 18). With so many parents working outside the home or with other commitments, we realize that you may not be able to accompany your child on every visit to the clinic. We require that a parent or legal guardian accompany your child to his or her first visit at our clinic. If your minor child presents to the clinic unaccompanied or in the company of an adult other than a parent or legal guardian, we may need to reschedule the appointment.
With so many parents working outside the home or with other commitments, we realize that you may not be able to accompany your child on every visit to the clinic. In an effort to provide the care needed in the most convenient and efficient way possible, we have developed an Advance Consent to Treat Minors form that, once completed by a parent or legal guardian, will be placed in your child’s medical record for use as necessary during any subsequent visits. This form will allow us to provide routine and emergency medical treatment for your minor child when deemed necessary by qualified medical personnel. This consent form will remain in effect until revoked in writing. You may request this form from any member of our clinic staff.
Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent. A minor may consent to medical care:
If the minor is emancipated (legally independent) or married to someone at or above age 18. • _(RCW 26.28.020)
In the event emergency care is necessary. (When impractical to get parental consent first)• _
For birth control and pregnancy-related care at any age. (See State v. Koome)• _
For outpatient drug- and alcohol-abuse treatment beginning at age 13. (RCW 70.96A.095)• _
For outpatient mental health treatment beginning at age 13.(RCW 71.34.500 and 71.34.530)• _
For sexually transmitted diseases, including HIV/AIDS, beginning at age 14. (RCW • _70.24.110)
If a minor consents to care as allowed by law, he or she can request confidentiality for that aspect of care which would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor’s express written permission.
It is the philosophy of this clinic to encourage minor patients to include a parent, guardian, or other trusted adult in all aspects of their health care including those areas noted above. For legal and other reasons, parent or guardian involvement may not always be possible. Rest assured that we would continue to provide health care services that are in the best interests of your minor child.
If you have questions regarding any of this information, please contact us at 425-654-1275.
When it comes to website security, we are especially paranoid. We have gone to great lengths to avoid having your Protected Health Information stored anywhere except where it actually belongs, which is in our Practice Management software.
The portions of our website that involved data collection are protected by SSL. The website is protected by SiteLock and our security processed are audited by Trustwave. However, for your protection, none of your information is stored or saved on our server.
Our website forms our transmitted via 256 bit SSL by a company called Formstack. No information is stored or saved by them either. Their transmission of information to us is protected by SSL with the addition of 2048 bit encryption and is sent to us by a HIPAA compliant email provider with which we have a Business Associate Agreement attesting to their security processes to protect your data.
We welcome input on any new or emerging technologies that could further augment security.
Basic Policy: Unless we accept your insurance plan, payment for service is due in full at the time service is provided in our office.
For Patients with Insurance: We are able to bill most insurance companies, both primary and secondary, for you. To allow us to do this for you, you must sign the Financial and Privacy Policies form provided. As of 2/1/14, we require that you place a credit card on file with our office (see our Credit Card On File Policy).
Ultimately, you are responsible for the full charges for the visit. If an insurance carrier has not paid within 60 days of billing, professional fees are due and payable in full from you. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for care.
In Network Coverage: For insurance companies that we are contracted with, we will determine your copay due at the time of visit, and bill your insurance for the balance. Depending on whether you have met your deductible and your coverage level, we will bill you later for the amount that insurance does not cover.
Out of Network Coverage: Miller Family Dermatology is not a network provider for First Health, Multiplan or Premera MedAdvantage (almost no one is, good luck), as well as some other small carriers. For these plans, your copay is still due at the time of visit. We will attempt to bill your insurance company for the balance. They will likely reimburse at a non-network provider rate. You are responsible for the remaining charges of the services provided, which may be higher than the charges for similar services provided by an in-network provider.
Medicare Patients: We will bill Medicare for you. In order to do this, we must have your signature on file. We will also bill secondary insurance carriers for you. All copayments are due at the time service is provided.
Non-covered Services (Cosmetic removals, cosmetic services): Cosmetic services cannot be submitted to insurance and payment in full is due at the time of service. We will not submit the charges for a service your provider deems to be cosmetic to your insurance company unless you have provided us with written prior authorization. This authorization must be obtained before the appointment for the service will be scheduled.
The patient is ultimately responsible for all professional fees.
All medications must be paid for at the time of purchase and cannot be charged to insurance.
Credit Card On File Policy
Miller Family Dermatology is committed to reducing waste and inefficiency and making our billing process as simple and easy as possible. We require that you provide a credit card on file with our office. We run our payments through our HIPAA-compliant, secure practice management software AdvancedMD. When you come in, we will scan your card with a card reader. Your payment information is stored on AdvancedMD’s secure servers for future transactions. Office personnel will not have access to your card. For your protection, only the last 4 digits of your card will show in our system. Credit Cards on File will be used to pay account balances after insurance adjudication.
Once your insurance has processed your claims, they will send an Explanation of Benefits (EOB) to both you and our office showing what your total patient responsibility is. You typically receive the EOB before we do, so if you disagree with the patient responsibility amount owed, it is your responsibility to contact your insurance carrier immediately.
When we receive the EOB, we will enter this information in our system. On the next Friday, if your total amount owed is $25 or less, we will process the payment on your card on file. If it is over $25, we will send out a statement showing your total responsibility. If you wish to give a different method of payment than the card on file or if you would like to split your balance into multiple payments, call our billing office at 425-654-4347 to make arrangements. Two weeks later on Friday (on the date listed on your statement), we will run the amount on the card on file (unless other arrangements have been made). If your payment is declined, we will call you to let you know on the next Monday.
If we receive no response by the next Friday, a $35 declined payment fee will be applied and a warning letter sent. In 10 days, if we receive no response, your account will be sent to Physicians and Dentists Credit Bureau for collections.
During the time you leave a credit card on file, if it expires or otherwise becomes uncollectable, we will expect you to promptly provide a new means of payment.
Credits on your account after your insurance claim has been adjusted will be returned to the credit card on file.
Should your credit card be mistakenly run, we will immediately issue a refund.
Ultimately, you are responsible for knowing what services are covered, how often, and how much of the cost is your responsibility. You will be responsible for any portion of services that your insurance does not cover.
Notice of Privacy Practices
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.
Miller Family Dermatology respects your privacy. We understand that your personal health information is very sensitive. The law protects the privacy of the health information we create and obtain in providing care and services to you. Your protected health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services.
We will not use or disclose your health information to others without your authorization, except as described in this Notice, or as required by law.
1. Your health information rights.
The health and billing records we create and store are the property of Miller Family Dermatology. The protected health information in it, however, generally belongs to you. You have a right to:
Receive, read, and ask questions about this Notice.
Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request unless the request is to restrict disclosure of your protected health information to a health plan for payment or health care operations and the protected health information is about an item or service for which you paid in full directly.
Request and receive from us a paper copy of the most current Notice of Privacy Practices (“Notice”).
Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing. We have a form available for this type of request.
Have us review a denial of access to your health information—except in certain circumstances.
Ask us to change your health information that is inaccurate or incomplete. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records.
When you request, we will give you a list of certain disclosures of your health information. The list will not include disclosures for treatment, payment, or health care operations. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
Ask that your health information be given to you by another confidential means of communication or at another location. Please sign, date, and give us your request in writing.
Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we receive the revocation. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, please contact:
HIPAA Privacy Officer - 425-654-1275
2. Our responsibilities.
We are required to:
Keep your protected health information private.
Give you this Notice.
Follow the terms of this Notice for as long as it is in effect.
Notify you if we become aware of a breach of your unsecured protected health information.
We reserve the right to change our privacy practices and the terms of this Notice, and to make the new privacy practices and notice provisions effective for all of the protected health information we maintain. If we make material changes, we will update and make available to you the revised Notice upon request. You may receive the most recent copy of this Notice by calling and asking for it, by visiting our office to pick one up, or by visiting our Web site, if we maintain one.
3. To ask for help or complain.
If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact:
HIPAA Privacy Officer - 425-654-1275
If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to the HIPAA Privacy Officer at Miller Family Dermatology. You may also file a complaint with the Department of Health and Human Services Office for Civil Rights (OCR).
We respect your right to file a complaint with us or with the OCR. If you complain, we will not retaliate against you.
4. How we may use and disclose your protected health information.
Under the law, we may use or disclose your protected health information under certain circumstances without your permission. The following categories describe the different ways we may use and disclose your protected health information without your permission. For each category, we will explain what we mean and give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose health information will fall within one of the categories.
Below are examples of uses and disclosures of protected health information for treatment, payment, and health care operations.
We may contact you to remind you about appointments.
We may use and disclose your health information to give you information about treatment alternatives or other health-related benefits and services.
Information obtained by a nurse, physician, or other member of our health care team will be recorded in your medical record and used by members of our health care team to help decide what care may be right for you.
We may also provide information to health care providers outside our practice who are providing you care or for a referral. This will help them stay informed about your care.
We request payment from your health insurance plan. Health plans need information from us about your medical care. Information provided to health plans may include your diagnoses, procedures performed, or recommended care.
We bill you or the person you tell us is responsible for paying for your care if it is not covered by your health insurance plan.
For health care operations:
We may use your medical records to assess quality and improve services.
We may use and disclose medical records to review the qualifications and performance of our health care providers and to train our staff.
We may use and disclose your information to conduct or arrange for services, including:
Medical quality review by your health plan,
Accounting, legal, risk management, and insurance services; and
Audit functions, including fraud and abuse detection and compliance programs
For fund-raising communications:
We may use certain demographic information and other health care service and health insurance status information about you to contact you to raise funds. If we contact you for fund-raising, we will also provide you with a way to opt out of receiving fund-raising requests in the future.
Some of the other ways that we may use or disclose your protected health information without your authorization are as follows.
Required by law: We must make any disclosure required by state, federal, or local law.
Business Associates: We contract with individuals and entities to perform jobs for us or to provide certain types of services that may require them to create, maintain, use, and/or disclose your health information. We may disclose your health information to a business associate, but only after they agree in writing to safeguard your health information. Examples include billing services, accountants, and others who perform health care operations for us.
Notification of family and others: Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital.
Public health and safety purposes: As permitted or required by law, we may disclose protected health information:Research: We may disclose protected health information to researchers if the research has been approved by an institutional review board or a privacy board and there are policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
To prevent or reduce a serious, immediate threat to the health or safety of a person or the public.
To public health or legal authorities:
To protect public health and safety.To prevent or control disease, injury, or disability.
To report vital statistics such as births or deaths.
To report suspected abuse or neglect to public authorities.
Coroners, medical examiners, and funeral directors: We may disclose protected health information to funeral directors and coroners consistent with applicable law to allow them to carry out their duties.
Organ-procurement organizations: Consistent with applicable law, we may disclose protected health information to organ-procurement organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.
Food and Drug Administration (FDA): For problems with food, supplements, and products, we may disclose protected health information to the FDA or entities subject to the jurisdiction of the FDA.
Workplace injury or illness: Washington State law requires the disclosure of protected health information to the Department of Labor and Industries, the employer, and the payer (including a self-insured payer) for workers’ compensation and for crime victims’ claims. We also may disclose protected health information for work-related conditions that could affect employee health; for example, an employer may ask us to assess health risks on a job site.
Correctional institutions: If you are in jail or prison, we may disclose your protected health information as necessary for your health and the health and safety of others.
Law enforcement: We may disclose protected health information to law enforcement officials as required by law, such as reports of certain types of injuries or victims of a crime, or when we receive a warrant, subpoena, court order, or other legal process.
Government health and safety oversight activities: We may disclose protected health information to an oversight agency that may be conducting an investigation. For example, we may share health information with the Department of Health.
Disaster relief: We may share protected health information with disaster relief agencies to assist in notification of your condition to family or others.
Military, Veteran, and Department of State: We may disclose protected health information to the military authorities of U.S. and foreign military personnel; for example, the law may require us to provide information necessary to a military mission.
Lawsuits and disputes: We are permitted to disclose protected health information in the course of judicial/administrative proceedings at your request, or as directed by a subpoena or court order.
National Security: We are permitted to release protected health information to federal officials for national security purposes authorized by law.
De-identifying information: We may use your protected health information by removing any information that could be used to identify you.
5. Uses and disclosures that require your authorization.
Certain uses and disclosures of your health information require your written authorization. The following list contains the types of uses and disclosures that require your written authorization:
Psychotherapy Notes: if we record or maintain psychotherapy notes, we must obtain your authorization for most uses and disclosures of psychotherapy notes.
Marketing Communications: we must obtain your authorization to use or disclose your health information for marketing purposes other than for face to face communications with you, promotional gifts of nominal value, and communications with you related to currently prescribed drugs, such as refill reminders.
Sale of Health Information: disclosures that constitute a sale of your health information require your authorization.
In addition, other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization. You have the right to cancel prior authorizations for these uses and disclosures of your health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we receive the revocation. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.
6. Web site
We have a Web site that provides information about us. For your benefit, this Notice is on the Web site at the following address: http://www.millerfamilydermatology.com/HIPAA/
7. Effective date
This Notice is effective as of September 18, 2013.