I authorize Wendy L. Matis, MD, and her staff to release any part of my medical record which is required to process an application for financial reimbursement for services rendered or medical supplies to my health insurance company or other third-party payer and to assign the benefits from such to be paid directly to Matis Dermatology. Consultation reports and medical records may also be released to other physicians to coordinate medical care. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I agree to be responsible for payment of all charges resulting from my medical evaluation and treatment. I understand that unless Dr. Matis is a contracted provider for my insurance company, payment is due at the time of service unless other arrangements are made prior to the beginning of treatment. I agree to make any co-payment and/or deductible payment required by my health insurance company at the time of service and agree to pay a $10 billing fee for any statement mailed to collect a co-payment.
I understand that payment in full (from all parties including my insurance company) is required within 90 days of the date of service unless specific arrangements are made in writing with the staff of Matis Dermatology. I agree to pay a monthly finance charge of 1.0% (12% annual interest rate) or $2.00, whichever is more, on any balance on my account that is outstanding for over 90 days. I understand that failure to make payment within 120 days may result in the referral of my account to a collection agency. In the event that collection or legal action is taken to obtain payment for services, I agree to pay reasonable collection fees up to 40%, which will be added to my total bill, with or without a suit, attorney fees, court costs, and other expenses that result from such action. I agree to pay $15.00 for any check returned by my bank for any reason.
In order for us, or for any other person or entity who provides goods or services to you in connection with this agreement, to contact you regarding servicing your account(s), including all past and current accounts, or to collect any amounts you may owe for any past or current account(s), you expressly authorize us to contact you by telephone at any telephone number, including any cellular, mobile, and other wireless telephone numbers that you have or may attain. You acknowledge that such calls could result in charges to you by your telephone carrier. You also expressly authorize us, and any other person or entity who provides goods or services to you in connection with this agreement, to contact you by sending text messages or e-mails to any of your telephone numbers or email accounts. Methods of contact may include the use of pre-recorded/artificial voice messages and/or the use of an automatic telephone dialing system, as applicable. You acknowledge and agree that this authorization shall extend to any billing or collection company or companies which may be assigned your account(s) for servicing or collection.
I accept responsibility for obtaining any written referral, prior approval or authorization for service required by my health insurance company or other third-party payers. I agree to pay the full cost of any service which is either disallowed by my health insurance company or which is not paid because such prior authorization was not obtained. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
If I fail to provide Matis Dermatology with my correct insurance information within one (1) week of my date of service I agree to be held personally responsible for all charges incurred. I understand my responsibility to provide a copy of my current insurance card at my appointment. If I failed to do so, I agree to either call, fax, or email Matis Dermatology with my insurance information or provide a copy of my insurance card(s) (front and back) to Matis Dermatology within one week of my visit. I understand that if I do not call, fax, or email in my insurance information within one week of the date of service, Matis Dermatology will bill me directly for any charges incurred for said date of service. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
*You may have a copy of this agreement upon request.
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