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Patient medication history is a list of prescription medicines that our practice providers, or other providers have prescribed for you. A variety of sources, including pharmacies and health insurers, contribute to the collection of this history. The medication history may include sensitive information including, but not limited to, medications related to mental health conditions, sexually transmitted diseases, substance (drug and alcohol) abuse and HIV/AIDS.

Obtaining your medication history is very important in helping healthcare providers treat you properly and in avoiding potentially dangerous drug interactions. Please note that some pharmacies do not make drug history available. Your drug history may not include drugs purchased without using your health insurance as well as over-the-counter drugs, supplements, or herbal remedies that patients take on their own.


By signing this consent form, you are giving your healthcare provider permission to collect information about your medication history, and it gives permission to your pharmacy and your health insurer to disclose your medication history. This includes specific consent to release sensitive health information listed in the first paragraph.

This consent will remain in effect until the day you revoke your consent. You may revoke this consent at any time in writing, but if you do, it will not affect any actions taken prior to receiving the revocation.

HIPAA Authorization and Consent



Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))


I understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:


• a basis for planning my care and treatment;

• a means of communication among the health professionals who may contribute to my healthcare;

• a source of information for applying my diagnosis and surgical information to my bill;

• a means by which a third-party payer can verify that services billed were actually provided;

• a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals


I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.


Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a))


I understand that:


• I have the right to review this facility’s Notice of Information practices prior to signing this consent;

• This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address I’ve provided if requested;

• I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.

• I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.

• It is this facility’s procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

Laboratory Results

If blood work is ordered, I understand that laboratory results will be discussed in person at the next scheduled visit. If I am unable to discuss the laboratory results in person at the next visit, I am required to call the office about 2-5 business days after blood work was taken to discuss the laboratory results over the phone with a California Dermatology Institute provider.

If a biopsy or surgical excision is performed, I understand that wound checks will be performed and laboratory results will be discussed in person at the next scheduled visit in about 2 weeks. If I am unable to come into the office for a wound check and discuss the laboratory results in person at the next visit, I am required to call the office 2 weeks after the procedure was performed to discuss the laboratory results and the wound healing process over the phone with a California Dermatology Institute provider.


The sample obtained in this procedure will be evaluated by a laboratory specialist. I understand that I may receive a separate bill from the laboratory for this examination.


Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.


By signing below, you acknowledge that you have received this notice and understand this policy.

Informed Consent to Treat Via Telemedicine

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:


Patient medical records

Medical images

Live two-way audio and video

Output data from medical devices and sound and video files


Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.


Expected Benefits:


Improved access to medical care by enabling a patient to remain at a remote site while being evaluated and treated by a healthcare practitioner at distant/other sites.


More efficient medical evaluation and management. Obtaining expertise of a distant specialist.


Possible Risks:


As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:


In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);


Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;


In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;


In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors;


By signing this form, I understand the following:

1.   I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent.


2.    I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.


3.   I understand that I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction, and may receive copies of this information for a reasonable fee.

4.    I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time.  My physician has explained the alternatives to my satisfaction.


5.    I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.


6.   I understand that it is my duty to inform my physician of electronic interactions regarding my care that I may have with other healthcare providers.


7.    I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine, have discussed it withmy physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize California Dermatology Institute to use telemedicine in the course of my diagnosis and treatment.

Insurance Signature on File

I certify that the information given by me in applying for Insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my Insurance and/or Medicare benefits, and I authorize payment of these benefits to Dr. Ezra on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer of the agency shown, and authorizes my doctor to act as my agent, as above.

Medication Consent

I hereby certify that I elect to have my prescription(s) dispensed by the providers of California Dermatology Institute.

I further certify that I have been advised that I have the right to be given a written prescription and fill these prescriptions at any pharmacy of my choosing, and have elected to have them dispensed by California Dermatology institute.

If California Dermatology Institute can not fill your prescriptions in the office, we will send them to a pharmacy that specializes in dermatology to help patients get their medications as soon as possible in the most convenient way.

If Patient is a minor (less than 18 years old) or mentally incompetent, this certification may be signed by a parent or guardian.

No Show/ Cancellation Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Therefore, patients who have a no show, cancellations or re-schedule for their appointment without at least 24 hours notice before the appointment time, California Dermatology Institute has the right to bill a fee of $45.00.


Fees will be billed to the patient. This fee is not covered by insurance and must be paid in full prior to your next appointment.

Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.

By signing below, you acknowledge that you have received this notice and understand this policy.

Office Financial Policy

By signing this document, I am agreeing to the terms of this Financial Policy.


PAYMENT AT TIME OF SERVICE: Payment of Copay, Deductible and or Coinsurance amounts are due in full at the time of service unless you are covered by Medi-Medi. You will be charged a $25 service fee for any returned checks, no exceptions.


INSURANCE: Patients will be asked to present their insurance card to the receptionist for copying upon check-in at the office each time they are seen for medical services. Please make it a point to bring your insurance card with you each time that you visit our office. Claims not paid within 45 days by your insurance company will automatically become your responsibility. You will receive a statement for these services and you will need to contact your insurance company for reimbursement.


For those patients covered by insurance plans with which we ARE participating providers, all co-payments, deductibles and noncovered services are due at time of service. We will file the insurance claim to the insurance company. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service and we will file your claim to the insurance company as a courtesy. Any charges that are not paid by

your insurance company are your responsibility. Your insurance policy is a contract between YOU and your insurance company. Any pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this.


Patients are required to leave a valid credit card on file, which will be charged the allowable amount deemed responsible by insurance.  As a courtesy we will notify you the patient, or legal guardian if any outstanding balance exceeds $200 dollars. It is the patient’s responsibility to verify if their insurance plan is one with which we participate.


COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency.

Advance Beneficiary Notice of Non-coverage (ABN)

NOTE: If your insurance doesn’t pay for any services below, you may have to pay. Your insurance does not pay for everything, even some care that you or your health care providers have good reason to think you need. We expect your insurance may not pay for some of the services.



• Read this notice, so you can make an informed decision about your care.

• Ask us any questions that you may have after you finish reading.


Please sign below after reading:


I want the services provided in this office. You may ask to be paid now, but I also want my insurance billed for an official decision on payment, which is sent to me in an Explanation of Benefits (EBN). I

understand that if my insurance doesn’t pay, I am responsible for payment, but I can appeal to my insurance by following the directions on the EBN If my insurance does pay, you will refund any payments I made to you, less copays or deductibles.

This notice gives our opinion, not an official Insurance Decision. If you have other questions on this notice or billing, please ask our staff. Signing below means that you have received and understand this notice.

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