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Information, Forms & Policies 2018-05-21T22:28:29+00:00

Since we value your time as much as we value your skin, please review the following information prior to your visit so we can focus our time on your skin care needs. Completion of patient documents prior to arrival will expedite the check-in process. All forms are available in a fillable format by request and will be sent through your patient portal account. Please contact our front office staff to request an electronic version.

To Help You Prepare

We want to make your first visit to Dayton Skin Care as pleasant and comfortable as possible. To better serve you, please bring your insurance card with you. If your insurance requires you to have a referral, please bring that with you at the time of your visit. You will be asked to fill out several forms on your first visit.

To save time, we offer the option of completing all of your necessary New Patient Information forms through our website. Simply print, complete and bring the New Patient Information Packet found at the link below with you to your first visit.

Mohs Surgery Patient Paperwork
General Dermatology Patient Paperwork

Note: Notice of Privacy Practices and Patient Rights are for your review and do not require printing, unless you would like to retain a copy for your records.

Privacy Practices
Nondiscrimination Practices

Dayton Skin Care Specialists complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

Scheduling

Please note that we try to accommodate everyone as quickly as possible. Patients with Melanoma will take precedence over other types of appointments. DSCS may call to move, reschedule or cancel your appointment based on the unpredictable nature of our business. Please understand that we are trying to meet the needs of our patients based on severity. We appreciate your understanding and cooperation if this occurs.

Please provide at least 72 hours notice if canceling a surgery to allow another patient the opportunity to fill your surgery date. Allow 48 hours cancellation notice if you need to reschedule a general dermatology appointment, follow up or full skin exam. Missing more than three appointments without providing at least 24-hour notice is grounds for discharge from the practice.

Payment Policies

Your insurance coverage is an agreement between you and your insurance company. Financial responsibility rests with the patient for co-payments, deductibles, co-insurances, and non-covered services. Insurance coverage is a variable and we cannot guarantee what services will be covered by your particular plan. If your insurance plan requires a referral from a primary care physician, you are responsible for obtaining the necessary referral. It is your responsibility to know the requirements of your insurance program. We will ask you to sign an authorization form requesting that insurance payments be sent directly to our office when appropriate.

We accept most insurance plans with a few exceptions. We are an out-of-network provider for all CareSource plans. We may be out-of-network with some Medicaid and some employer plans. If you are uncertain, please check with your insurance plan.

United Healthcare Medicare Plans require pre-approval.

Please call our office to inquire if you have questions.

All applicable co-payment, deductible and coinsurance and outstanding balances will be collected at time of service. Full payment is required for all non-covered services.

For your convenience, we accept personal checks, Visa, MasterCard, Discover, Care Credit and cash.

If you have any questions or concerns, please contact our billing department at 937-293-5567, option 4.

Nonpayment of your account balance may result in transfer of collection efforts to an outside collection agency and credit damage. In the event your account is referred to a collection agency or attorney for collection, you will be responsible for all collection fees, attorney fees, court costs, and expenses. A $30.00 fee will be added to your account for each returned check.

There is no charge for cosmetic consults with our aesthetician. Patients who have a cosmetic consult with a physician will receive credit in the amount of the consult toward their cosmetic procedure, if scheduled and performed within 6 months.

Cosmetic service and Laser patients will be required to make a $100 deposit at the time of scheduling. The deposit will be credited toward the service cost at your visit. We require 24 hour notice to cancel of reschedule your appointment. If you cancel with less than 24 hours notice or no-show for the appointment, you will forfeit your deposit. Deposits will not be refunded.

Sculptra requires a credit card on file and signed acknowledgement of financial policy at time of consult. Product must be constituted a number of days prior to injection, therefore we require 5 days notice to cancel or reschedule your appointment. Failure to provide a minimum of 5 days notice will result in a charge of $400 per vial to cover the cost of product loss.

Package purchases must be paid in full at the time of scheduling. Refunds will only be made if requested prior to the first treatment. No refunds will be made following the first treatment, whether subsequent treatments are used or unused.

Dayton Skin Care Return Policy:
Unused/Unopened Product: 15 days from the purchase.
If you experience an adverse/allergic reaction, contact the office within 2 business days of purchase. Returns will be accepted at the physician’s discretion.
Clarisonic Returns: Contact Clarisonic Customer Service at 888-252-2742

Biopsies may be sent to a lab to be analyzed. The fee for this is a separate charge from the office visit. You may receive a bill from Dayton Skin Care for the physician service and a separate bill from the processing lab. Results are usually available 7-10 days after the test has been performed. Questions regarding payments for laboratory services should be discussed with the lab.