Skin Care Patient Center

Prior to your first appointment at Cheyenne Skin Clinic, fill out the following forms:

Patient Registration Form

Medical History Form

Medicare Form

Medical Release Form

Bring your printed, completed forms and a photo ID with you to your appointment. Or email your forms to patients@cheyenneskinclinic.com. If you have any questions, call our office.

At the Cheyenne Skin Clinic, our goal is to provide quality dermatological care in a timely manner. We have implemented an appointment/cancellation policy which enables us to better utilize available appointments for our patients in need of dermatological care.

Scheduled Appointments

To schedule an appointment by telephone, please call 307-635-0226.

Cancellations of Appointments

Please be courteous and call the Cheyenne Skin Clinic promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in urgent need of treatment.

If it is necessary to cancel your scheduled office appointment we require that you give at least 24 hours notice. Available appointments are in high demand and your early cancellation will give another person the possibility to have access to timely dermatological care.

Surgical Appointments

Cancellation of scheduled surgeries require 24 hours notice. Because of the necessary supplies and equipment allotted for surgical procedures, any cancellation not made prior to the 24 hours will be subject to a fee of $50.00 to $100.00. This fee will not be billed to insurance.

How to Cancel Your Appointment

To cancel appointments call the Cheyenne Skin Clinic at 307-635-0226 or 800-736-0226.

“No Show” Policy

A “no show” is someone who misses an appointment without canceling it by 10:00 a.m. (1) one working day in advance. No-shows inconvenience those individuals who need access to dermatology care in a timely manner.

A failure to present at the time of a schedule appointment will be recorded in the patients’ chart as a “no show”. Three “no shows” in one semester may result in the temporary suspension of services.

The Cheyenne Skin Clinic and Center for Dermatological Surgery adopts and affirms as policy the following rights of patients who receive services from our facility. As a patient, you have the right to:

1. Informative Disclosure: You have the right to receive accurate and easily understood information about your health status, health care professionals, and health care facilities. If you speak another language, you have a physical or mental disability, or simply do not understand what you are being told, assistance will be provided to you to make your informed health decisions.

2. Choice of Providers: You have the right to choose your health care provider and know the identify and professional status of the individuals providing service to you.

3. Access to Emergency Services: If you are in severe pain, have sustained an injury, or a sudden illness that convinces you that your health is in serious jeopardy, you have the right to receive screening and stabilization emergency services whenever and wherever is necessary.

4. Participation in Treatment Decisions: You have the right to know all your treatment options and to make an informed decision regarding your care. You have the right to participate in the development, implementation and revisions regarding your healthcare. You have the right to request, accept or refuse treatment. You have the right to be informed of potential consequences of treatment refusal.

5. Know our policy concerning Advanced Directives: The Center for Dermatological Surgery does not accept Advanced Directives because we are an outpatient facility, using only local anesthesia. Per a mandate from the Wyoming Legislature and State Law, The Aging Division of the Wyoming Department of Health is to make available the most current approved version of the State’s Advanced Directives. If you need assistance with this or you do not have access to the internet, please let us know, we do have copies of these forms available to you at your request.

6. Respect, Safety and Nondiscrimination: You have the right to be treated with respect, dignity and comfort. You have the right to consider nondiscriminatory care from your physicians and other healthcare providers.

7. Confidentiality of Health Information: You have the right to speak in confidence to your healthcare providers and to have your healthcare information safeguarded from unauthorized disclosure in accordance with HIPPA guidelines.

8. Patient Responsibilities: You are responsible for providing, to the best of your knowledge, accurate and complete information about your health statue and past medical history and reporting unexpected changes to your healthcare provider. You are responsible for being considerate of the needs of other patients in the facility and providing healthcare insurance information and financial obligations.

9. Grievances and Appeals: You have the right to a fair, fast and objective review of any grievance you have against your doctors, nurses or other healthcare personnel. This includes grievances about waiting time, operating hours, conduct of healthcare personnel and adequacy of the facility. Grievances may be written or verbal. Please ask your nurse or healthcare personnel for a grievance form. Resolution to your grievance will be within a reasonable time frame, usually within 30 working days, and you will be informed of the progress of the resolution. Grievances should be reported to Cheyenne Skin Clinic & Center for Dermatologic Surgery, Attn: Teresa Lake, Facility Administrator, 123 Western Hills Boulevard, Cheyenne, Wyoming 82009 (307) 635-0226. However, if concerns are not satisfactorily resolved at the facility level, a complaint can be filed with the OHLS by calling (307) 777-7123 or fax a completed complaint form to (307) 777-7127. Written complaints against Wyoming healthcare facilities can be mailed to: Office of Healthcare Licensing & Surveys, 400 Qwest Building, 6101 Yellowstone Rd., Cheyenne, Wyoming, 82002. Medicare patients may also contact the offices of Medicare Beneficiary Ombudsman.

If you have any questions regarding your patient rights or responsibilities, please discuss your concerns with our staff.

Ownership

The physicians and facilities listed below are limited partners in the Center for Dermatologic Surgery. An interest in this facility enables them to have a voice in the administration and medical policy of this health care institution. This involvement helps to ensure quality surgical care to their patients.

Sandra K. Surbrugg, M.D.
Julie A. Neville, M.D.

Payment Policy

Co-payments are due the day of your visit. If you are not prepared to make your co-payment, your appointment WILL BE RESCHEDULED.

As a courtesy to our patients, Cheyenne Skin Clinic will bill any insurance. HOWEVER, payment in full is due at the time of service unless CSC is contracted with your insurance company. Our receptionists will be happy to answer any questions regarding whether or not CSC is contracted with your insurance company. Patients with insurance will be expected to pay their co-insurance or percentage due, as well any unmet deductibles UPON CHECKING OUT. Patients with no insurance coverage will be expected to PAY IN FULL AT EACH VISIT (including lab work and other testing). Please notify the receptionist of any changes in address, phone number or insurance coverage.

CSC accepts cash, personal checks, credit cards (Visa, Mastercard, American Express, Discover) and debit cards.

Refund Policy

Cheyenne Skin Clinic accepts cash, personal checks, credit cards (Visa, Mastercard, American Express, Discover) and debit cards.

While Cheyenne Skin Clinic makes all reasonable efforts to estimate the patient’s out of pocket or co-payment due at the time of service, occasionally overpayments may occur. If Cheyenne Skin Clinic becomes aware of an overpayment or mistake in payment (either through the Cheyenne Skin Clinic’s discovery, or by notification of the patient), the Cheyenne Skin Clinic will process this overpayment either back to the patient or to the insurance, whichever is indicated. Refunds are processed every thirty days. Please let us know if you have an urgency for reimbursement. If an overpayment is indicated and you would like to request a refund in writing, please send a letter of explanation, including the patient’s name, date of birth and date of service and request for overpayment to:

Cheyenne Skin Clinic
Attn: Patient Refunds
123 Western Hills Blvd
Cheyenne, Wyoming 82009

Also, discovery of overpayments or questions regarding a balance may be addressed by calling Cheyenne Skin Clinic at 307-635-0226.

Cheyenne Skin Clinic attracts residents from all corners of Wyoming. We also see patients who travel from as far as the Front Range in Colorado to the western plains of Nebraska. We work with the following insurance providers:

• Medicare
• First Choice
• Multiplan
• United Healthcare
• BCBS
• Tri-Care
• UPREHS
• GEHA
• Great West
• Medicaid (Wyoming and Nebraska)
• Midlands Choice
• Regional Care
• Mail Handlers
• First Health
• UP and UP Pro America
• Champ VA

Not sure if we work in-network with your insurance policy? Contact our office today.

Cheyenne Skin Clinic works with Medicare patients. Read and fill out our Medicare Patient Form to learn more.

Our Policy

Your trust is very important to us and our Practice is strongly committed to protecting your privacy. We have created the following Website Privacy Statement to give you an overview of the type of information we collect, how the information is used and how the information is safeguarded.

Our goal at the Cheyenne Skin Clinic is to take appropriate steps to attempt to safeguard any personal information that is provided to us. We are required to:

• Maintain the privacy of medical information provided to us.
• Provide notice of our legal duties and privacy practices.
• Abide by the terms of our Notice of Privacy Practices currently in effect.

Changes to Our Policy

Our Practice may make changes to the Privacy Statement at any time. If we do so, we will post those changes on our Website so you are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. Please review our Privacy Statement periodically to see recent changes.

Addressing Policy Concerns

If you have any questions about this Privacy Statement please contact us at:

Cheyenne Skin Clinic
Attn: Teresa K. Lake , Practice Administrator
123 Western Hills Blvd.
Cheyenne, WY 82009
patients@cheyenneskinclinic.com

What Information Is Collected?

This Privacy Statement applies only to information collected through our Website. Our Practice collects information about you through the information you provide to us.

In order to provide you with certain services through our Website, we may collect information from you. In some cases, our Practice asks you directly for information in order for you to use our services. For example, if you wish to request products through our website, we collect certain information to fulfill your order.

In some areas of our Website, we may collect certain information that you provide in order to use our services. Such information may include:

• Contact information, such as name, mailing address, e-mail address and phone number.
• Shipping or transaction information, such as billing address and credit card information, if you choose to purchase goods from our Practice.
• Information provided in connection with online registration for educational series or other events offered through our Website.
• Demographic information such as zip code, age and gender.
• Patient contact information such as name, mailing address, phone number, e-mail address and medical and insurance information.
• Information you enter in forms and optional surveys.
• Information provided in e-mail requests and communications.

What Information Is Shared with Third Parties?

Our Practice may disclose information you provide to us to independent contractors, service providers and consultants who assist us in providing healthcare services to you via our Website. Such providers may include, without limitation, credit card processing and shipping companies. However, we will only share such personally identifiable information, as we deem necessary for them to carry out their obligations to our Practice.

We may also share aggregated demographic information with independent contractors, service providers, consultants and other partners. This is not linked to any personal information that can identify any individual person. Our Practice may also disclose personal information that can identify any individual person. Our Practice may also disclose personal information it has collected if necessary to fulfill our service obligations or if we are required to do so by law, or if in our good faith judgment, such action is reasonably necessary to comply with legal process.

Linking

Our Website may offer links to other Websites. Please be aware that we are not responsible for the privacy Practices of such linked Websites, including Websites of our partners. We encourage our users to be aware when they leave our Website to read the privacy statements of each and every Website that collects personally identifiable information. This privacy statement applies solely to information collected by our Website.

Disclaimer

Unfortunately, no data protection method or combination of methods can be guaranteed 100 percent secure. We strive to protect your personal information as described throughout this policy, but we cannot ensure or warrant our ability to do so. As a result, you use our content, products, and services at your own risk. We will not be liable for disclosures of your personal information due to errors in transmission or unauthorized acts of third parties.

No Surprises Notice

Rights & Protections Against Surprise Medical  Bills