Financial Responsibility Form

Patient Financial Responsibility

• YOU ARE RESPONSIBLE to ensure that both your referral and insurance are valid on the date of your visit to Dermatology Specialists of North Florida, P.A., and for all treatment provided. Our office participates with most major insurance plans and we make a good faith effort to ensure that we are in-network providers for all insurance accepted. However, due to the rapidly changing healthcare market, it is ultimately the patient's responsibility to verify that our providers are participating providers with your specific plan. As a courtesy, our office will file your insurance claim with the information you provide us one time per visit; if we receive a denial or no timely response, you will be responsible for payment.
• Co-payments and payment for cosmetic and non-covered procedures are collected on the date of service. We accept cash, check, Visa, MasterCard, or Discover.
• The fee for a missed appointment without one working days notice via phone call to the office is at least $35.00. The fee for a missed surgery/procedure without three working days notice is ½ the fee or at least $100.00.
• In the event your account is turned over to a collection agency or attorney for recovery, you will be responsible for all associated collection costs.
• If applicable, I request that payment of authorized Medicare benefits be made to our providers for any services furnished to me by the practice of Dermatology Specialists of North Florida, P.A. I authorize any holder of medical information about me to release to the Center for Medicare & Medicaid Services and its agents any information needed to determine these benefits for related services.

MY SIGNATURE CERTIFIES THAT I HAVE READ AND UNDERSTOOD MY FINANCIAL RESPONSIBILITIES AND THAT I AUTHORIZE MY INSURANCE COMPANY TO REIMBURSE DERMATOLOGY SPECIALISTS OF NORTH FLORIDA, P.A. FOR MY 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.