Fee for Service, Private or General Insurance
Thank you for choosing our practice. We want to make every experience you have with us a positive one. Over the past few years, the practice of medicine has become more complicated for physicians and patient alike.
Because of the growing complexity of the insurance business, we feel we can no longer assume that patients fully understand the relationship between the insurance company, the doctor and themselves. In an effort to clarify this relationship, we have developed a set of guidelines regarding financial responsibility. If you have any questions, please speak with the office staff, You will be asked to sing the end of the form.
Payment is expected at the time of service.
We will give you the necessary forms for submission to your insurance carrier for a partial reimbursement of fees incurred. The amount reimbursed by your carrier may be adjusted, according to your plan provisions.
Determining Our Charges
An office visit charge includes discussing your complaints with the doctor, your examination and assessment, and any treatment given by prescription. Many times patients are unaware that when procedures are performed in the office they are not necessarily included in the charge for the office visit. Procedure charges would include such things as performing a biopsy, removing or destroying a skin lesion, performing cosmetic procedures (see below), or drawing blood for a laboratory test. Please be aware that if a procedure is done during an office visit, this may add to the total cost of your visit. If you have any questions about our charges, please ask us before we perform a procedure. We do not generally discuss cost of procedures unless you ask.
If you have no insurance and feel like you cannot afford a procedure you need, please let us know. We will do whatever we can to help someone who needs care but has an inability to pay at the time services are rendered.
Please recognize that the practice of medicine is not an exact science and acknowledge that there are no guarantees or assurance concerning the result of procedures.
Not Medically Necessary or Cosmetic Procedures.
The following procedures are routinely considered not medically necessary or cosmetic. Your insurance carrier may not reimburse you for these services (including office visits for evaluation of these conditions):
- Removal of benign lesions (moles, warts, skin tags, cherry or spider angiomas, lentigos or liver spots, cysts, milia and seborrheic keratoses)
- Collagen treatments
- Glycolic acid or other chemical peels
- Ear Piercing
- Scar Revision
- Laser surgery for certain benign lesions
- Cautery for treatment of dilated blood vessels on the face
- Hair Loss
Laboratory and Pathology Fees.
Many times it is necessary to obtain tissue or perform lab tests to confirm a diagnosis or to determine a course of treatment. If any tissue is removed for a pathology examination or if a laboratory test (blood work, culture, etc.) is done in our office, the actual testis usually carried out by someone else
THIS MEANS YOU WILL RECEIVE A SEPARATE BILL FROM ANOTHER DOCTOR OR LAB FOR THESE TESTS.
Forms of Payment
We accept cash, personal checks, Mastercard and Visa.
Estimation of Services
We will be happy to give you an estimate of fees when this is possible. Please remember that only the doctor can give you an accurate estimation of the cost of a procedure since he will determine the exact procedure to be performed. Please keep in mind that it is only an estimate of costs. Unforeseen circumstances could cause the actual cost of a procedure to increase when done at a later date. The only time we can assure you of the exact cost of a procedure is on the day of service when the doctor has determined the actual coding to be used. Also, please remember that the estimate of our charges will not include work done by any outside lab or pathology service.
There is a fee of $40.00 for all returned checks.
We will send you FOUR statements regarding your balance. On the THIRD statement of 1.5% services charge will be added to your balance. If you should receive a FOURTH statement noted "FINAL" the account balance will be turned over to a collection agency. There will be a 35% service charge to any outstanding balance that is turned over to a collection agency. All fees charged are your responsibility.
By signing below, I am indicating that I do not have a government plan such as MEDICARE or MEDICAID or CHIPS or STAR.
I have read and understand the above completely and agree to comply with the financial policies of this office. I understand that my signature also allows this office to release information regarding my visits to my insurance carrier should they request additional information about a claim that I file.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.