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The form also addresses SCCDS financial and billing policy, including nonwaivable co-pay responsibilities, a $5.00 processing fee after the first billing statement, and delinquent account handling after 90 days with possible collection-agency, attorney, and court-cost fees. Signature, date, relationship, and staff initials fields are provided.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/sccds-hipaa-form-template-authorization-and-financialbilling-practice/307464/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/sccds-hipaa-form-template-authorization-and-financialbilling-practice/307464.png","ImageObject",442,249,{"name":88,"@type":89},"WPS_1786070896","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",8,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What patient PHI disclosures does the form authorize SCCDS to make?","Question",{"text":109,"@type":110},"It authorizes SCCDS to use or disclose PHI for office tracking and appropriate staff sharing, appointment communications, disclosures explicitly consented to on the SCCDS Release of PHI form, disclosures required by law, referrals and related medical coordination, tissue samples to outside laboratories, and insurance-related payment information. It also covers employer work-excuse limitations and pharmacist-related prescription information.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form describe patient co-pay and insurance responsibilities?",{"text":114,"@type":110},"All co-pays and insurance-determined patient responsibilities are stated as nonwaivable and non-refundable. Noncompliance by the patient or provider with the insurance contractual agreement is described as fraudulent and punishable by law, with potential termination of patient insurance benefits and/or termination of the provider’s insurance contract.",{"name":116,"@type":107,"acceptedAnswer":117},"What happens if a billing balance remains unpaid?",{"text":118,"@type":110},"After the first billing statement, any unpaid patient balance is subject to a $5.00 processing fee. For delinquent accounts, outstanding balances 90 days after the date of service are treated as delinquent, potentially leading to collection-agency referral with additional 30–50% collection fees and any attorney fees or court costs paid by the patient.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307464,1790147531,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4},549768072016,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESAnd FINANCIAL/BILLING PRACTICE  \nPlease read and initial the following St. Charles County Dermatologic Surgery (SCCDS) Patient PHI Disclosure, the SCCDS financial and billing policy, and sign and date the form.  \nHIPPA Authorization for Use of Disclosure of Patient Protected Health Information (PHI)  \nI authorize SCCDS to use or disclose my PHI according to the following scenarios:  \n1. Tracking my health records, appointments, consults, billing, and treatments in the SCCDS office and sharing with appropriate office staff.  \n2. Contacting me regarding appointment scheduling, requesting additional appointment information or other pertinent health related concerns. Releasing or discussing my medical information to anyone I have explicitly consented to on the SCCDS Release of PHI form. Providing my medical information as required by law.  \n3. Providing tissue samples and related information to an outside laboratory if my consult and/or treatment requires.  \n4. Requesting my medical information from the referring physician’s office as necessary for my consult and/or treatment. Updating my referring physician of my consult and/or treatments.  \n5. Providing my medical information to another physician that I have accepted a referral to from this office.  \n6. Providing my insurance company the required information for payment of my consult and/or treatment.  \n7. Providing my employer pertinent medical information for work excuse or limitations.  \n8. Providing information required by the pharmacist when prescription in relation to my consult and/or treatment.   Initial to acknowledge you read and accept the SCCDS Patient PHI Disclosure.  \nPlease read and initial the following SSCDS financial and billing policy:  \n1.  Co-pay and patient responsibilities: All co-pays and insurance determined patient responsibilities are nonwaivable and non-refundable. Failure for either patient or provider to comply with their respective insurance contractual agreement is considered fraudulent and punishable by law. Furthermore, failure to comply my result in termination of patient insurance benefits and/or termination for the provider insurance contract.  \n2.  Billing statement processing fee: Any unpaid patient balance after the first billing statement will be subjected to a $5.00 processing fee.  \n3.  Delinquent Accounts: Once third-party payment has been determined, outstanding balances 90 days after the date of service are considered delinquent. If the patient indicates they will not pay and/or defaults on payment arrangements previously established, the account is turned over to a collection agency. If this occurs, an additional 30-50% fee charged by the collection agency as well as any attorney fees or court costs incurred to collect the debt, will be paid by the patient.  \n  Initial to acknowledge you read and accept the SCCDS Patient PHI Disclosure.  \nPatient Name   Patient DOB    \nSignature   Date  (Patient or Legally Authorized Representative)  \nRelationship (Legally Authorized Representative to Patient)    \nSCCDS Staff Initials   \n1493 COTTLEVILLE PARKWAY, COTTLEVILLE, MO 63376 [SCCDermSurgery.com](SCCDermSurgery.com) • 636-317-DERM  \n5/14/2020 – REV 2","cbCaioHyaY8M6FhN","https://ap.wps.com/l/cbCaioHyaY8M6FhN","pdf",699908,"English","# HIPAA Authorization for Use/Disclosure of PHI\n# Financial/Billing Practice Policy\n## Co-pay and patient responsibilities\n## Billing statement processing fee\n## Delinquent accounts","[{\"question\":\"What patient PHI disclosures does the form authorize SCCDS to make?\",\"answer\":\"It authorizes SCCDS to use or disclose PHI for office tracking and appropriate staff sharing, appointment communications, disclosures explicitly consented to on the SCCDS Release of PHI form, disclosures required by law, referrals and related medical coordination, tissue samples to outside laboratories, and insurance-related payment information. It also covers employer work-excuse limitations and pharmacist-related prescription information.\"},{\"question\":\"How does the form describe patient co-pay and insurance responsibilities?\",\"answer\":\"All co-pays and insurance-determined patient responsibilities are stated as nonwaivable and non-refundable. Noncompliance by the patient or provider with the insurance contractual agreement is described as fraudulent and punishable by law, with potential termination of patient insurance benefits and/or termination of the provider’s insurance contract.\"},{\"question\":\"What happens if a billing balance remains unpaid?\",\"answer\":\"After the first billing statement, any unpaid patient balance is subject to a $5.00 processing fee. For delinquent accounts, outstanding balances 90 days after the date of service are treated as delinquent, potentially leading to collection-agency referral with additional 30–50% collection fees and any attorney fees or court costs paid by the patient.\"}]","SCCDS HIPAA Form Template - Authorization and Financial/Billing Practice | PDF",1789849912]