Payment is required for all services. If you have insurance, your payment is based on your negotiated contracted rates with your insurance company. You are responsible for any copays, deductibles, coinsurance, any non-covered services, and usual and customary amounts for non-contracted insurance. Co payments and unpaid balances will be collected at the time of service at check-in. If you are unsure of your copay, deductible, or coinsurance amount, please contact your insurance company for clarification prior to your appointment. I understand that in the event that services are not covered under my insurance, I accept full financial responsibility for all non-covered services. For patients without insurance, $200.00 will be collected during check- in and the remaining balance based on the services provided will be collected at checkout. For cosmetic visits, a $150.00 cosmetic consultation fee will be charged when the appointment is made, this will be applied to the cosmetic service fee if a procedure is completed within 3 months. The remaining fee for the cosmetic service will be collected at checkout on the day of the procedure. Cosmetic fees are non refundable. You will be sent a statement to the physical address or email address you have on file. You will be responsible to contact the office if you have a change in either address. Once the final statement is sent, your account may be sent to our legal collection agency. I acknowledge that I shall be responsible for the collection agency fee or the actual collection cost to the practice. At this point, all contact regarding your account must then be made with the legal collection agency’s account representative. If you need to set up a payment plan, please call the office prior to your visit. I further acknowledge that there is a $25.00 banking fee for all returned checks.
If a referral is required by my health insurance plan, I understand that it is my responsibility to obtain the referral from my primary care provider and assure that it is available at the time of my visit. I further understand that it is my responsibility to keep track of the number of visits I have used, the expiration date, and obtain a new referral as needed. I understand that should I fail to have a valid referral at the time of my visit, I will need to pay the cancellation fee and reschedule.
Should you be unable to keep the appointment, please cancel at least 24 hours prior to the appointment time. Cancellations must be on a business day, (i.e. Monday appointments need to be cancelled on Friday). Otherwise, there is a cancellation fee of $50 for general dermatology appointments & $100 for surgical and cosmetic dermatology appointments.
INSURANCE CARD POLICY
All patients new and returning are required to present their current insurance card(s) at every visit. I understand by signing below that I am responsible for notifying the office of any changes to my insurance or contact information.