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David Fivenson, MD, Dermatology, PLLC
3001 Miller Road, Ann Arbor, MI 48103
Phone: 734-222-9630
Fax: 734-222-9631
email: fivensondermatology@comcast.net
OFFICE POLICIES AND PROCEDURES
Thank you for choosing our office for your medical dermatology needs. If we can improve our service, please let us know.
Office hours
-Our office will be open M-F from 8:00am to 5:00pm, with appointments scheduled from 8am to 4:15pm.
-When our office is closed during a regular workday, the answering service will give instructions on leaving a message or who
to call with questions.
-We will try to be available to help you with any questions that might arise related to your skin conditions, and will try to have
a ‘live’ person answer every phone call. Email is a very efficient way to communicate with us and we encourage this way to
get your questions answered (if a personal call is not needed).
Appointments
NO-SHOW/CANCELLATION POLICY
-It is our policy to encourage patients to arrive and receive care at their scheduled arrival time, or to give appropriate
notice of cancellation to allow other patients to receive timely care.
-If you are unable to make your scheduled arrival time, we request that you notify us as soon as possible, but no later
than 24 hours prior to your scheduled arrival time. Additionally, we request that you arrive at your scheduled arrival
time.
-By either not providing 24 hour notice or arriving late, you may be assessed a $50.00 fee for a missed office visit.
If three (3) or more appointments are missed, our office reserves the right to terminate our relationship with you.
It is not our intent to assess an additional financial burden, but it is costly if you miss your appointment and do not give
us time to schedule another patient in your time slot.
-Minor children (age 17 and younger) must be accompanied by their parent or legal guardian.
Prescription Refills
We require 48 hours notice for all prescription renewals
For mail-in prescriptions, be sure to allow time for insurance verification/authorizations
-We will fill prescriptions for topical medications (at our discretion) up to one (1) year after the last office visit and internal
medications (at our discretion) up to six (6) months after the last office visit.
-To refill a prescription, we will need the following information for each prescription you are requesting:
•
Your full (legal) name,
•
Date of birth
•
Name of the drug, medication vehicle (i.e. cream, lotion, solution, gel or ointment and the size or number of tablets
previously prescribed.
•
Strength
•
How often it is taken
•
Pharmacy name, location and phone number – be specific
•
Daytime phone number and an alternative number where you can be reached, your daytime phone number, the
pharmacy name and phone number, your type of insurance, the medication name, dose previously prescribed, the medication
vehicle (i.e. cream, lotion, solution, gel or ointment and the size or number of tablets previously prescribed.
-Please feel free to leave this information on our answering machine or email it to us. Please allow up to three days for
prescription refills to be processed.
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David Fivenson, MD, Dermatology, PLLC
3001 Miller Road, Ann Arbor, MI 48103
Phone: 734-222-9630
Fax: 734-222-9631
email: fivensondermatology@comcast.net
Laboratory Studies
-We send most biopsy specimens and blood work to St. Joseph Mercy Hospital in Ann Arbor.
-It is your responsibility to inform us if your insurance requires use of a different laboratory for lab/ pathology services. Please
be aware that these services are billed separately from our office fees.
-We are happy to notify patients by mail or telephone of any or all laboratory results. If you have not heard from us in 2 weeks
please call and leave us a message. If you would like your results left as a phone message or sent by email, please authorize
this below.
Billing
-Payment is due at the time of service, unless Dr. Fivenson participates with your insurance. All co-pays are due at the time of
service. We accept cash, check, MasterCard or Visa. Please ask prior to your appointment if you have any other concerns
regarding our fees.
-Patient statements will be mailed monthly by our billing service and prompt payment of remaining balances is appreciated.
-There will be a $50 service charge for any check returned to us from the bank.
-Balances of greater than 60 days past due will be subject to a 2 % monthly fee.
Remember many of these insurance companies are HMO’s and require a referral to see a specialist. Verify this with
your individual plan to see if a referral is required and be sure to bring it with you to your appointment. If a referral is
necessary and you have not requested one from your primary care physician, you will be responsible for paying for
your visit in full.
Privacy Statement
We respect that your personal information is private and will only exchange such information with those parties whom we have
your permission to and only as part of your health care in Dr. Fivenson’s practice. Confidential health care information is only
released with your permission to other health care providers. Your health care information may also be shared with your
insurance company to allow us to collect for Dr. Fivenson’s services. Details of our HIPAA Policy are available for your
review.
PLEASE SIGN BELOW
I give my consent for treatment:
Signed ___________________________________________ Date ___________
Print Name: ___________________________________
I understand the above policies and have been advised of and offered to review the practices
HIPAA Privacy policies.
____________ (Initial)
I have read the above and consent to phone messages or email notification of laboratory results. _____________ (Initial)
I hereby give my consent to Dr. Fivenson to access and download my medication
history electronically into my chart.
___________ (Initial)
I hereby give my consent to Dr. Fivenson to have results of any procedures or blood work from St. Joseph Hospital clinical
laboratory be sent electronically through Lifepointe (an HL7 partner interface) into my chart.
______________ (Initial)