Your first visit to Burnett Dermatology involves a few special steps so that we can get to know you. To understand what to expect, please read through this page. You'll find all the practical information you need, such as a
map and directions
to our office, practice hours, payment policies and more.
There's also background information about our committed staff and our first visit procedures. You can also save some time by printing out and completing the patient forms in advance of your appointment.
Our practice is working together to realize a shared vision of uncompromising excellence in dermatology.
To fulfill this mission, we are committed to:
- Listening to those we are privileged to serve.
- Earn the trust and respect of patients, profession and community.
- Exceed your expectations.
- Ensure a creative, challenging and compassionate professional environment.
- Strive for continuous improvement at all levels.
Please print and fill out these forms so we can expedite your first visit:
In order to view or print these forms you will need Adobe Acrobat Reader installed.
Click here to download it.
HIPAA – Health Information Portability and Accountability Act
We protect your privacy in every way possible. Our office strictly adheres to the HIPAA law. All employees are fully trained on HIPAA guidelines and all of our office technology is carefully designed to provide maximum protection of your personal information. We never share your information with anyone not directly involved with your care, insurance or billing without your consent.
All patients must complete and sign our HIPAA policy form. All patients are also requested to present their photo ID at each visit. These are HIPAA requirements specifically designed to protect your identity from misuse. Please refer to our “Notice of Privacy Practices” posted in the lobby and on our website.
We strive to provide exceptional medical care in a timely manner. Our staff understands your time is precious and that changes may occur with little notice. To efficiently serve all of our patients we require a 24-hour notice for all cancellations. This provides us enough time to offer your valuable appointment time to another patient. Late arrivals may be asked to reschedule.
Appointments cancelled with less than 24-hours notice may be charged a cancellation fee.
- Surgery / Cosmetic visit $100
- Skin check / Focused visit $25
As a courtesy to you, the first no-show fee may be waived based on circumstances. It is our strong desire to create a lasting relationship built on mutual respect. We do everything we can to accommodate your schedule and we thank you in advance for your cooperation.
Please allow us up to two days to process your refill request. Most refills are generally completed within one business day. To maintain the highest clinical standards, we require at least an annual exam for prescription refills. Your provider may require more frequent visits depending upon the medical condition.
The fastest way to obtain your refill is for your pharmacist to directly fax/email the request.
Prescription refills are a routine procedure and we gladly perform them during normal business hours. Any refill requests made after-hours (ie. on the emergency line) may incur an additional fee.
We adhere to a clear and comprehensive financial policy. As a courtesy to all of our patients, it is our normal practice to:
- Verify eligibility and benefits prior to your appointment.
- File your claim with Medicare and/or commercial healthcare insurance providers.
For All Patients
- Payment is required at the time of service unless prior arrangements have been made.
- I am responsible for knowing the terms of my policy, including deductibles, copayments, coinsurances and any applicable referral procedures.
- I am financially responsible for all charges, whether or not covered by insurance. This includes, but not limited to, out-of-network and cosmetic service charges. 9 All pathology and/or laboratory fees are billed independently of Burnett Dermatology and are ultimately my responsibility.
- Burnett Dermatology’s billing department will contact patients with overdue accounts. Every effort is made to help our patients satisfy their obligations in a reasonable manner.
- In the event we are unable to verify your benefits or you cannot provide proof of coverage at the time of visit, I can either:
- Reschedule my appointment, or
- Make payment in full. We will provide financial statements to help you pursue reimbursement of the claim (upon request).
Option 1 – Medicare
My initial here and full signature below indicates that I hereby:
- Authorize Burnett Dermatology to release all information necessary to process my claims to CMS and its agents.
- Assign any insurance payments (both Medicare and Medigap insurances) to be paid directly to Burnett Dermatology.
- Understand this Assignment will remain in effect until revoked by me in writing. I also understand that:
- All Medicare beneficiaries without Medigap (ie. secondary insurance) coverage are responsible for paying the required 20% copayment at the time of service.
Option 2 – Commercial Insurances (ie. PPO, HSA)
Burnett Dermatology will release all information necessary to process my claims to my insurance company and its agents
- Assign any insurance payments (both primary and secondary insurances) to be paid directly to Burnett Dermatology Understand this Assignment will remain in effect until revoked by me in writing. I also understand that:
- My healthcare insurance is a contract between my insurer and me.
- It is my responsibility to verify benefits for my particular plan and to make certain all proper authorizations have been obtained.
- If I do not obtain the necessary referral I understand that I am solely responsible for all costs of the services provided.
- It is my responsibility to satisfy any outstanding balances at the time of service, including: annual deductibles, copayments, out-of-network costs and/or coinsurances.
Option 3 – Self-Pay Policy
Dr. Burnett kindly extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of his self-pay patients. Burnett Dermatology Self-Pay Policy requires self-pay patients to pay $100 upon check-in.
At the end of the visit:
- Any charges in excess of the collected amount must be satisfied.
- Any overpayments made will be refunded.
- Dr. Burnett extends a 10% discount on all services typically covered by commercial insurance as a courtesy to all of his self-pay patients.
Self-pay patients may be eligible for discounted rates with local pathology laboratories.
What To Expect
Being well-prepared for your appointment will ensure that the doctor has all of the needed information to provide the best possible care for you. It will also help alleviate any unnecessary anxiety you may be feeling prior to your first appointment. Educate yourself on your symptoms by reviewing the content on this Web site. Also, take some time to review our staff page and familiarize yourself with the doctors. We look forward to your first visit.