OFFICE POLICIES & PROCEDURES

INSURANCE

Kittridge Dermatology is a direct care practice, is out of network for all 3rd party insurance payers, and makes no representation that your claim will be reimbursed partially or in its entirety by your health insurance company. This means that patients pay Kittridge Dermatology directly for their care.

Upon request, a coded receipt may be provided for privately insured patients to submit on their own behalf to their insurer. If requested retrospectively, after the date of service, there may be a fee to request a coded receipt.

All questions regarding your insurance coverage and reimbursement should be directed to your insurance company or benefits manager. Kittridge Dermatology will not communicate with any insurance provider or benefits manager.

MEDICAID, MEDICARE. MEDICARE SUPPLEMENTS AND TRICARE

We do not participate in any government healthcare program. Those insured by these government plans, cannot submit claims to Medicaid, Medicare, Tricare or any of its supplements for services provided at Kittridge Dermatology. Medicaid, Medicare and other government insurance programs WILL still cover any medications or testing prescribed by Dr. Kittridge as per your policy.

PRIVATE CONTRACT

All patients seen at Kittridge Dermatology must engage in a private contract before services can be rendered. This contract states that Kittridge Dermatology does not make any representations that any fees paid to Kittridge Dermatology are covered by your health insurance or other third party payment plans that apply to you. Dr. Kittridge has opted out of Medicare and does not participate with Medicaid, and as a result, these agencies cannot be billed for any services performed for you by Dr. Kittridge at Kittridge Dermatology. You agree not to bill or attempt reimbursement from Medicaid, Medicare or any government insurance for any such services.

PAYMENT

Payment in full is required at the time that any services are rendered. Cash, Visa, MasterCard and Discover are accepted forms of payment. A credit card on file is required to book some appointments but is not charged unless there is a violation of our cancellation policy. In some instances, a deposit must be collected to reserve your appointment. You will be notified beforehand if this is the case.

Health spending (HSA) and flex spending (FSA) accounts are accepted for all medically necessary services.

GENERAL DERMATOLOGY FEE SCHEDULE

A fee schedule is posted on the website and available at the office upon request. Fees are subject to change at any time without notice.

COSMETIC FEE SCHEDULE

Cosmetic services are billed under a separate fee schedule. As always, payment is due at the time of service. However, some planned, larger procedures may be charged before services are rendered. A cosmetic consultation is required for all new cosmetic patients, or established cosmetic patients who wish to discuss new treatment plans.

OTHER FEES

Pathology Fee. We have negotiated discounted fees for pathology with preferred labs. You may choose to pay our cash fee OR have pathology billed through your insurance.

Other Fees. Occasionally, there may be an additional fee for staff time, administrative work, or other extra tasks that are done on your behalf. We will inform you if extra fees are involved. These include medical coding fees (10$ per request) and prior authorization work for prescriptions (25$).

CHANGES TO FEES

Fees are subject to change at any time without notice.

CREDIT CARD ON FILE (CCOF) POLICY

The purpose of this policy is to ensure that patients have a convenient, efficient and safe option to pay for their medical or cosmetic care.

REQUIREMENTS. If required to put a credit card on file (CCOF) when booking your appointment, the credit card must be in the name of the patient or the patient’s authorized representative.
USE OF CREDIT CARD. The credit card on file will be used to pay for any unpaid balances. The credit card will also be used to pay for any no-show, late-cancels, or other purchases or services.
CREDIT CARD DISPUTES. To avoid fraudulent payment disputes and cancellations, a $200 fee may be assessed if Kittridge Dermatology has followed all fiscal protocols and procedures.
CHANGES TO CC INFORMATION. Patients are responsible for keeping their credit card information up-to-date.
SECURITY. Kittridge Dermatology takes security of patient information very seriously. The credit card information provided is stored within the credit card processing system. Credit card information is not stored directly within our electronic medical record system.

INSURANCE REIMBURSEMENT

For privately insured patients, upon request, we can provide the necessary information for you to file a claim with your insurance company. However, we cannot guarantee that your insurance company will reimburse you. All questions regarding your insurance coverage and reimbursement should be directed toward your insurance company or benefits manager.

LATE CANCEL AND NO-SHOW

Late cancellations or missed appointments (no-shows) prevent other patients from being seen in a timely manner. We require 24 BUSINESS hours notice for cancellation or rescheduling. For example, our office is closed on Fridays, therefore Monday appointments must be cancelled by Thursday at 12pm to avoid late cancellation fees and to provide the office with an opportunity to offer the appointment time to another patient.

For appointments that are 30 minutes or less the late cancel/no show fee is $100. For appointments >30 minutes, the late cancel/no-show fee is $200.

LATE ARRIVALS

To avoid inconvenience to other patients, Kittridge Dermatology will do its best to accommodate a late arrival with an abbreviated visit (no procedures) for the remainder of your scheduled time if it is possible and within reason for the medical staff. However, you will be charged for the full amount of your appointment time regardless of arrival time.

PACKAGE TREATMENTS

Patients have one year from the date of package purchase to receive their treatments. We understand that extenuating circumstances arise and will work with you to accommodate your schedule. Package purchases are non-refundable and non-transferable.

PRODUCT RETURN POLICY

ALL products and prescriptions purchased in the office, whether opened or unopened, are non-refundable. If possible, we will be happy to offer you a sample to test a product prior to purchase.

Any products purchased from our online store (via RegimenMD LLC) must be returned directly through RegimenPro. RegimenMD, LLC offers a 60-day, money-back guarantee to original consumer purchasers of products purchased through the RegimenPro online ordering platform (“Warranty”). If you purchased your product through RegimenPro.com and you are dissatisfied for any reason within 60 days of the date of purchase, please contact RegimenPro’s Customer Service at customerservice@regimenpro.com or 855-576-1800 to arrange for the product to be returned.

PRESCRIPTIONS & REFILLS

To purchase prescription products from the office, you must be a currently registered patient of the office. Refills may be given for up to 1 year from the last office visit at the discretion of the medical staff. Refill requests may be declined based on potential side effects, failure to present for follow-up visits, or extended absence from the practice.

GIFT CERTIFICATES

Available in any denomination, our gift certificates do not depreciate or expire. Gift certificates are non-refundable

SAFETY & PRIVACY

The use of recording devices in the office or exam rooms is prohibited. Any unauthorized recording or photography may result in dismissal from the practice.

All firearms/weapons regardless of conceal-to-carry permits are prohibited on our premises. Please store your firearm in your vehicle or leave it at home.

GOOD FAITH ESTIMATE

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 877-696-6775.

Although Kittridge Dermatology is not subject to the Health Insurance Portability and Accountably Act (HIPAA), we nevertheless choose to provide privacy rights similar to those you expect from your other medical providers and we remain subject to all applicable Pennsylvania laws as well. We prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.

You have the following rights with respect to your PHI:

The right to revoke previous authorizations in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.
The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a requested restriction in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of PHI by alternative means or at alternative locations.
The right to inspect, copy and amend your PHI.
The right to receive an accounting of disclosures of your PHI.
The right to obtain a paper copy of this notice from us upon request.
The right to be advised if your protected PHI is intentionally or unintentionally disclosed.

We may use and disclose your medical records only for each of the following purposes:

Treatment- providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this is a primary care doctor referring you to a specialist doctor or a specialist doctor communicating with your primary care doctor.
Payment including such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review.
Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service.
The Practice may also be required or permitted to disclose your PHI for law enforcement purposes, public health reporting, abuse and neglect, regulatory agencies, judicial and administrative proceedings, coroners, medical examiners, funeral directors, threats to health and safety, military/veterans, workers’ compensation, marketing/fundraising, appointment reminders, information about treatment alternatives or health-related benefits and services, other uses and disclosures permitted by the Privacy Regulations.
We may also create and distribute de‐identified health information by removing all reference to individually identifiable information.
With notification or a proper authorization we are permitted to disclose your health information to Business Associates and to allow Business Associates to receive your health information on our behalf. A Business Associate is an individual or entity under contract with us to perform or assist us in a function or activity which requires the use of your health information. We require all Business Associates to protect the confidentiality of your health information.

The following uses and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

Most uses and disclosure of psychotherapy notes;
Uses and disclosures of your PHI for marketing purposes, other than if such communication is conducted face-to-face or concerns products or services of nominal value
Disclosures that constitute a sale of PHI under HIPAA; and
Other uses and disclosures not described in this notice.

We are required by Pennsylvania law to maintain the privacy of your PHI and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

This notice is effective as of July 23, 2018 and it is our intention to abide by the terms of the Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provision effective for all PHI that we maintain. We will post a copy and you may request a written copy of the revised Notice of Privacy Practices from our office.

You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with the Pennsylvania Board of Medicine. We will not retaliate against you for filing a complaint.

TERMS AND CONDITIONS

Kittridge Dermatology is an information service provided by Ashley Kittridge, DO, at no charge to users of the world wide web, with the express condition that users agree to be bound by the terms and conditions set forth in this terms of use agreement.

Ashley Kittridge, DO reserves the right to change these terms and conditions at any time, and you agree to abide by the most recent version of the terms of use agreement each time you view and use this website. You are accordingly advised to consult the terms of use agreement each time you view and use the website. Do not use the website if you do not agree to all of the following terms and conditions. This website and the information contained herein are copyrighted and may not be used or copied without permission of the owner, Ashley Kittridge, DO.

The information provided on kittridgedermatology.com is intended for informational purposes only. It is in no way intended to substitute for medical advice or consultations with qualified health professionals who are familiar with your individual medical needs. Ashley Kittridge, DO makes no guarantees, warranties, or representations of any kind regarding the information contained on kittridgedermatology.com, with respect to any procedure, treatment, or application of any medication or preparation. Ashley Kittridge, DO makes no guarantees, warranties, or representations of any kind regarding the accuracy, completeness, currency, reliability, merchantability, or fitness for a particular purpose of the information contained herein, or any representation, guarantee, or warranty that these pages, or the computer server which makes them available, are free of viruses or other harmful elements, and such warranties are expressly disclaimed.

Ashley Kittridge, DO makes no guarantees, representations, or warranties with respect to her practice of medicine. Ashley Kittridge, DO opinions and methods of diagnosis and treatment change as new information, techniques, and treatments become available. The information contained on kittridgedermatology.com cannot and does not necessarily represent Ashley Kittridge, DO most current thoughts and practices. Kittridge Dermatology will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the information provided by or on kittridgedermatology.com.

You agree that you will hold harmless Ashley Kittridge, DO and its shareholders, officers, directors, and employees from all claims arising out of or related to your access or use of, or your inability to access or use, kittridgedermatology.com or the information contained in kittridgedermatology.com or other websites to which it is linked, including but not limited to claims that you have found or something that you have heard, viewed or downloaded from kittridgedermatology.com or any other website to which it is linked to being obscene, offensive, defamatory, or infringing upon your intellectual property rights. In no event will Ashley Kittridge, DO be liable to you or anyone else for any decision made or action taken by you in reliance on such information or for any consequential, special or similar damages, even if Ashley Kittridge, DO has been advised of the possibility of such damages. Kittridgedermatology.com may contain links to other websites which are not under the control of Ashley Kittridge, DO and makes no guarantees, warranties, or representations regarding these websites which are intended for reference purposes only. Ashley Kittridge, DO makes no endorsement of any kind with respect to the organizations or individuals operating these websites or the information contained on these websites.

HEALTH INSURANCE REIMBURSEMENT/CLAIMS FORMS

Kittridge Dermatology makes no representation that your claim will be reimbursed partially or in its entirety. For privately insured patients, upon request, we can provide the necessary information for you via a coded superbill to file a claim with your insurance company (there is a small charge to cover the physician’s time). Additionally, you will need to print and complete the appropriate reimbursement form and submit to your insurance. To make this process easy and simple, we have provided the claims forms for the most common insurance companies below. If you do not see the appropriate form for your insurance you may use the Universal Health Insurance Claim Form and should contact your insurance to make sure no other specific form needs to be completed. All questions regarding your insurance coverage and reimbursement should be directed toward your insurance company or benefits manager.

Please note that by law Medicare and Medicaid patients cannot submit for reimbursement.

UPMC HEALTHCARE Claim Form

Highmark BCBS Healthcare Claim Form

United Healthcare Claim Form

United Healthcare How To Submit A Claim

Aetna Healthcare Claim Form

Universal Health Insurance Claim Form

OTHER FORMS:

Medical Records Release Form