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.
As a participating provide, we accept assignment of benefits and file all Medicare claims for you.
Please be aware that Medicare does not pay us the total charges allowed at the time of your visit. You will be responsible for 20% of the total charges at each visit. Furthermore, each calendar year you begin a new deductible with Medicare. If your deductible has not been met for the year, we will ask for payment up to your deductible amount at the time of your visit.
If your secondary insurance plan is part of Medigap (sent electronically by Medicare), your signature will allow us to file claims and assigns to this office all rights, title, and interest to your medical reimbursement benefit under your insurance policy.
Medicare sets the fees that we may charge
Any procedure not covered by Medicare (see below) will be identified at the time of service. Medicare does not set the fees for services that are "not medically necessary" and you will be asked to pay for these procedures at the time of services.
Not Medically Necessary or Cosmetic Procedures.
In order to keep health care costs down, Medicare has put restrictions on some previously covered procedures. Our office is aware of many of these not medically necessary or cosmetic procedures and will attempt to alert you to these procedures when possible. If you and the doctor decide to continue with a procedure that falls into this category, we require payment in full at the time of service. There is no reduction in fees for Medicare patients when cosmetic procedures are performed.
The following procedures are routinely considered not medically necessary or cosmetic.
Medicare may not cover 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
- All forms of Hair Loss
- Acne surgery
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
If you receive a bill from a lab, please contact that lab directly to resolve any billing concerns.
Forms of Payment
For your convenience, 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.
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 signing below, I am indicating that I do not have a government plan such as MEDICAID or CHIPS or STAR.
I have read and understand the above completely and agree to comply with the financial policies of this office. My signature authorizes this office to file my claims and assigns to this office all rights, title and interest to my medical reimbursement benefits under my insurance policy.
I understand that my signature also allows this office to release information regarding my visits to my insurance carrier. I understand that I am responsible for my bills in the event the insurance company denies any claims.
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.