We are committed to providing you with quality medical care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or responsibility.
To assist us in establishing your account please (1) provide current insurance information on the patient registration form and (2) authorize the release of information necessary for insurance filing and pre-certification. Failure to do so will affect your financial responsibility for charges incurred. Your payment can be in the form of cash, check, or credit card.
Contracted Managed Healthcare Plans ( PPO, POS, EPO): Each time you make an appointment, it is your responsibility to make sure that this office is currently under contract with your plan(s), and you have obtained the necessary referrals. Verification of your plan is required. Often, this verification requires us to share the reasons for your visit with your managed care plan. Please plan to show your current insurance card(s) and a picture id (e.g. Driver's license) to our staff upon request. Co-payment, co-insurance, deductible, and/or fees for non-covered service are required at the time of service.
Insurance is a contract between your insurance company and you. We are not a party to your contract. We will not become involved in disputes between your insurance company and you regarding deductibles, non-covered/covered charges, coinsurance, secondary insurance, coordination of benefits, pre-existing conditions, or “reasonable and customary” charges, other than to supply factual information as necessary. You are responsible for the timely payment of your account, and /or your dependents' accounts.
Many services performed in our office (biopsies, liquid nitrogen, etc,) are considered surgical procedures by your insurance company. These services may be covered by your insurance company but may be subject to a deductible or co-insurance. Any deductible, co-insurance, or non-covered service, is your responsibility to pay, and we may ask for payment at the time of service. Surgical procedures may include but are not limited to: treatment of warts and molluscum; removal of moles, skin cancers, benign growths and cysts; treatment of pre-skin cancers; acne surgery; keloid treatments; nail plate biopsy/ clipping; and drainage of abscesses.
After 60 days, it is the patient's responsibility to pay the balance on their account even if there's an insurance claim pending. We will no longer be responsible for collecting your insurance claim or for negotiating a settlement of a disputed claim.
Any account past due more than 60 days may be assessed an interest charge per month on the unpaid balance and a $30.00 billing fee. If my account is referred to a collection agency, or credit-reporting agency, or a lawyer, I agree to pay all associated costs incurred. Any amounts due from me cannot be discharged in bankruptcy and are binding on me, my assigns, heirs, executors, or estate.
Unless canceled or rescheduled at least 24 hours in advance, our policy is to charge a $50 fee for missed appointments. This fee is not covered by insurance. Please help us serve you better by keeping your scheduled appointment.
This agreement applies and relates back to all occasions of service until Sugar Land Dermatology revokes or replaces it. A copy of this agreement serves as an original.
I have read and understand the above terms and conditions and will verify so by giving my signature.
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.