Patient: Date:

With my consent, Fair Oaks Skin Care Center, Ltd, and their employees ("The Practice") may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations. (Please refer to The Practice's Notice of Privacy Practices for a more complete description of such disclosures. I also understand I have the right to review the Notice of Privacy Practices prior to signing this consent.)

With my consent, the Practice may call my home or other designated location to leave messages on voice mail or in person in reference to any items that assists the Practice in carrying out appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results etc.

Phone number to call:

With my consent, the Practice may mail to my home or other designated location(s) any items that assist the practice in appointment reminders and patient statements.

With this consent I understand that all co-pays are to be paid at the time of service and that all past due balances that reach 90 days are sent to a collection agency and the responsible party is liable for any charges and legal fees incurred by our office as result of this action. There will be a $50.00 charge for Medical No-Show or appointments without 24-hour prior notification and a $100.00 charge for No-Show or appointments without 24-hour prior notification for cosmetic appointments. There may also be a $30.00 fee assessed with any prior authorizations for prescription drugs.

By signing this form, I am consenting to Fair Oaks Skin Care Center, Ltd. and its employees' use and disclosure of my Protected Health Information (PHI) to carry out treatment, payment and healthcare operations.

The following individually identifiable health information - test results, social, mental and physical health, appointment information, billing and/or billing related account information, complete history and physical information and demographic information may be disclosed to the parties listed below.

Name of Person: Relationship to me:
Specify Disclosure:

SIGNATURE OF PATIENT/RESPONSIBLE PARTY:

DATE: