Central Carolina Dermatology Patient Information

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Central Carolina Dermatology welcomes our established and new patients to our website!

You will find answers here to many questions you may have.

Visit Information

  • Please arrive 10 minutes prior to your scheduled appointment, to update your information into your electronic health record via an iPad and sign forms.
  • Authorization for Release of Information Form
  • If you are unable to keep your appointment, please notify our office at least 24 hours in advance to avoid a missed appointment fee.
  • You are required to bring your photo ID, current insurance card (s), current medication list and payment for services rendered.
  • Please bring someone with you to your appointment if you require assistance to and from your vehicle.
  • Minor patients must have a parent or legal guardian present with photo identification at the time of the appointment. Legal guardians should bring court documentation for the patient file. Please fill out form below for a new minor patient.
  •  Consent for Treatment of Minor Child 

Prescription Refills

Please contact your pharmacy if you need a medication refill. We only process refill requests during normal office hours. Please allow 2 business days for refill processing.

Privacy Policy

Our Privacy Policy describes how medical information about you may be used and disclosed and how you can get access to the information. You can review our Privacy Policy below.

Medical Records Release Information

To request a copy of your medical records, or have your request sent to another provider, print and complete the release below. You can send the release to us by mail, fax (336-887-3194) or email ( medicalrecords@centralcarolinaderm.com ) There may be a fee associated with this request.


Request Access to Personal Health Information


You may also complete a release if you would like Central Carolina Dermatology to request a copy of your record to be sent to us from another provider.


Request to Release Records to CCD

Patient Bill of Rights

  • A patient has the right to good quality care and high professional standards that are continually maintained and reviewed. 
  • A patient has the right to have his or her medical records treated under the HIPAA guidelines for privacy. 
  • A patient has the right to make informed decisions regarding his or her care and has the right to include family members in those decisions as long as they meet the HIPAA guidelines. 
  • A patient has the right to have any service, procedure, or fee explained upon request. 
  • A patient has the right to be treated with respect.

 

Insurance Plans We Participate With

Aetna / Coventry / First Health-Wellpath: GEHA, Mail Handlers, APWU, NALC (includes, HMO, QPOS, Aetna Choice Pos, Elect Choice, Managed Choice, Open Choice, HMO Open Access, Open Select, National Advantage


Blue Cross Blue Shield: 

  • Blue Advantage
  • Blue Care
  • Blue Options
  • Blue Select
  • Blue Value
  • State PPO
  • We are NOT participating with Blue Local or Blue Home


Cigna: Open Access Plus, PPO, HMO (includes Great West, formerly One Health Plan) 

  • Cigna HealthSprings


Healthgram


Humana: Choicecare PPO & POS 


Medcost 


Medicare: AARP Medicare HMO & PPO, Aetna Medicare HMO & PPO, Aetna Medicare Prime HMO & PPO, Blue Medicare Advantage PPO & HMO, Coventry Medicare, Health Team Advantage, Humana Medicare, United Healthcare Medicare Assisted Living Plan, Dual Complete, Group Medicare Advantage, Medicare Direct (PFFS) and United Healthcare Nursing Home Plan (Most HMO Plans requires a referral)   

             

PHCS: PPO or MD Plan, Multiplan, Medishare (not PHCS if card says POS Plan).


Tricare: Tricare Select, Tricare For Life, Tricare Prime (needs referral)


United Health Care: Advance Choice and Advanced Choice Plus, All Savers, Choice and Choice Plus PPO, Heritage, Options PPO, Navigate HMO needs referral.  (Most HMO Plans require a referral)


FREE CLINICS: Davidson Medical Ministries of Lexington


Devoted Health

Billing for Office Visits and Surgical Procedures

We want to help you understand how medical insurance covers office visits and procedures. When you have a co-payment, some insurance carriers apply it to the office visit. Any procedure done in the office such as freezing or removing skin lesions, treating warts with medication, skin biopsies is considered a surgical procedure according to the American Medical Association. When these surgical procedures are medically necessary, they may be covered by your plan, but usually fall under a different section of your insurance coverage and subject to a deductible. It is important for you to understand your insurance coverage so you will not be surprised when you get your explanation of benefits from your insurance carrier and bill for our services.

When possible, and desired by you, the provider will evaluate your condition and perform the procedure during the same appointment time. However, should you wish to have a cost estimate of your procedure before it is performed, Central Carolina Dermatology will contact your insurance company after you leave the office and call you when the estimate is prepared. You can then schedule an appointment for the procedure if you choose to proceed. 

Central Carolina Dermatology accepts:

  • Cash 
  • Check 
  • Visa 
  • MasterCard 
  • Discover 
  • Care Credit 

Consent for Treatment of Minor

I, being the parent or guardian of

do hereby request and authorize Central Carolina Dermatology physicians and staff to perform necessary

services for my child which are deemed advisable by the physician, whether or not I am present at the actual appointment.


Below is a list of individuals who have permission to bring my child in for treatment:





Consent for Treatment of Minor Child

Without Adult Present


I, being the parent or guardian of

, do hereby request and authorize Central Carolina Dermatology physicians and staff to perform necessary services for my child which are deemed advisable by the physician, without an accompanying adult or guardian present.


Request to Release Records

Robert T. Migliardi, MD     Edward S. Smith, MD     Carlin B. Hollar, MD     Joshua S. Butler, MD             Kyle H Flores, MD    Elyshia M. Warden, PA-C    


REQUEST TO RELEASE HEALTH INFORMATION TO A HEALTHCARE PROVIDER FOR CONTINUED TREATMENT


Name and Address of Healthcare Provider or Facility authorized to release information:

Forward Information to: Central Carolina Dermatology Clinic, Inc. 

231 Harmon Lane

Kernersville, NC 27284

336-996-1173

Fax: 336-996-7694

4010 Mendenhall Oaks Pkwy

High Point, NC 27265

336-887-3195

Fax: 336-887-3194

6 Medical Park Drive

Lexington, NC  27292 

336-249-2404

Fax: 336-249-7283

Please forward the following information for Continued Treatment:

Rights of the Patient

Treatment will not be conditioned on signing this authorization and the patient has the right to refuse to sign this authorization.  It is understood that information disclosed as a result of this authorization may be subject to redisclosure by the recipient and may be longer be protected by federal or state law.

Request for Access to Personal Health Information

For email communication - I understand that if information is not sent in an encrypted manner there is a risk it could be accessed inappropriately. I elect to receive email communication as requested.


You will be notified regarding this access request no later than 30 days from the date received. There are limited circumstances where your request may be denied. Certain denial decisions may be reviewed at your request.

Central Carolina Dermatology Clinic, Inc

Authorization for Release of Protected Health Information

Authorize Central Carolina Dermatology Clinic, Inc to release the following Protected Health Information verbally and/or in writing

The information above may be released verbally and/or in writing to the following persons/entities:

Rights of the patient


I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information that will be disclosed as described in this document by sending a written notification to the Privacy Officer.  I understand that a revocation is not effective in cases where the information has already been disclosed, but will be effective when received by Central Carolina Dermatology Clinic, Inc.


I understand that information used /disclosed as a result of this authorization may be subject to redisclosure by the recipient; therefore the information will no longer be protected by federal or state law.


I have the right to refuse to sign this authorization and my treatment will not be conditioned on signing this authorization.


This authorization remains in force and effect until revoked in writing by the patient or representative signing this authorization.