FDL Dermatology Out-of-Network (OON) Financial Policy
FULL PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT Cash, Checks, Visa, MasterCard, AMEX, Discover.
Out of Network Benefits: We do not accept assignment of insurance benefits for all payers less select BlueCross & BlueShield (BCSS) Policies. We do require you pay what is not covered by your insurance at the time of service. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company. You will be responsible for this process. We will provide you with a Walk-out Receipt, which will display your procedure (CPT) and diagnosis (ICD-l0) codes. This is the extent of our involvement in the process.
Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please be aware that some, and perhaps all, of the services provided may be non-covered
services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance.
Please also be aware that your out-of-network benefits are different from your in-network benefits and likely much higher in terms of your liability. It is highly likely that your benefit levels are lower than what your insurance company would pay, and thus the entire "payable" amount will be applied to your deductible.
In Network Benefits: Regarding Insurance Plans where we are a participating provider. Only select BCSS plans. All co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan where we are not participating providers, refer to above paragraph.
Usual and Customary Rates: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
Missed Appointments: Unless canceled at least 24 hours in advance, our policy is to charge $50.00 for missed appointments. Please help us serve you better by keeping scheduled appointments.
Interest and Collections: We reserve the right to charge interest in the amount of 9% as provide by state law. Additionally, for accounts transferred to collections, we do charge a Collections Transfer Fee of 25%.
I have read the financial agreement and understand that I am ultimately responsible for the full debt for services incurred for treatment at FDL Dermatology. My insurance benefits have been explained to me and I fully understand it is my insurance's responsibility to explain what my insurance has verified that they will pay. I also understand verification of benefits is not a guarantee of payment and I am ultimately responsible for any balance with FDL Dermatology.
Thank you for understanding our Financial Policy and fully waive FDL Dermatology for all rights and responsibilities otherwise associated with my claims. Please let us know if you have questions or concerns.
I have read the Financial Policy. I understand and agree to this Financial Policy:
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