Forms and Policies

Forms & Policies

 

Download, complete and submit all paperwork to Sunflower Dermatology at least 5 days prior to your appointment to help ensure a smooth and timely experience. You can email completed forms to us at patient@sunflowerdermatology.com or you may fax them to us at (816) 472-0813.

If you want to apply for credit to cover your out of pocket expenses, we recommend Care Credit.

CareCreditLogo2

Our financial policy is available to print by downloading the form below.

FINANCIAL AGREEMENT:

  • All contracted insurance are billed directly to your insurance company as a courtesy of Sunflower Dermatology and Medical Day Spa LLC (SFD). Any remaining balances for non-covered benefits deductibles, copays and coinsurances are your responsibility.  These may be collected prior to any potential procedure.  It may take up to three months or longer for your insurance to process your claim.  Therefore, the charge to your credit/debit card may be delayed.
  • We require a copy of a valid credit or debit card to be kept on file. You will not receive a bill but will receive an EOB (explanation of benefits) from your insurance company explaining costs incurred.  Monies due to SFD based on your EOB, will be charged to the card on file upon our receipt of the EOB.
  • ______________Please initial acknowledging the above statement.
  • There is a $30 fee for all returned checks.
  • Out of respect for all patients waiting to see the doctor, there will be a $75 fee for no showing to appointments.
  • All accounts that become past due 45 days after your insurance pays, we reserve the right to send your account to a collection agency if the balance is not paid in full within 60 days.
  • For all skin lesion removals (i.e. cosmetic or medical), a skin specimen is sent to the pathology lab for testing and to confirm clinical diagnosis. There may be additional charge by the lab, unrelated to any fee paid directly to Sunflower Dermatology and Medical Day Spa, LLC
  • A copy of this form will be available at your request.
  • I authorize the release of medical information to my primary care or referring physicians, to consultants if needed and as necessary to process insurance claims, insurance applications and prescriptions. I also authorize payment of medical benefits to the physician.
  • I hereby acknowledge that I have read, understand and agree with the policies set forth by Sunflower Dermatology & Medical Day Spas LLC and any change made by me will be made only in writing. I give my authorization for the charge of my valid debit/credit card and my consent for procedures as outlined above.

 

I consent to the financial agreement above.

______________________________        ______________________________        ___________

Name of patient                                                      Signature of patient                                               Date

______________________________        ______________________________        ___________

Name of parent/guardian                                    Signature of parent/guardian                            Date

 

 

NEW PATIENT FORMS

(Must complete and submit all 3 forms at least 5 days prior to appointment)

 

RELEASE FORMS

There are 2 forms in the attachment below to help you request files to be transferred TO us or FROM us to someone else.

If you need your records from our office, there may be a fee for copying.

 

Wound Care Instructions

(Just click on the name of the instructions you need and a PDF will come up)

Cryosurgery Instructions

Post Surgery Wound Care

Biopsy Wound Care


 

For Referring Physicians Only