Patient Financial Policy Form

Alabama Dermatology Associates

Please correct the errors described below.

Thank you for choosing Alabama Dermatology Dermatology Associates as your dematology care provider. Your clear understanding of our Patient Financial Policy is importan to our professional relationship. Please carefully review the following information and return this form with your signature and today's date. Your signature indicates that you understand our policy and that you agree to meet all the financial responsibilities explain therein.

Charges incurred for services rendered by Alabama Dermatology Associates are your responsibility, regardless of insurance coverage. Assignment will be accepted for all insurances with which our practice participates. It is your responsibility to provide this office with accurate insurace information, and to notify us of any charges in health insurance coverages. If you have questions or network status/participation with your insurance, it is your responsibility to contact your insurance company directly.

Payment for cosmetic procedures will be required when the procedure is scheduled or at the time the services is provided, at the providing physician's discretion.

Self-Pay Patients are required to pay $100.00 prior to seeing the healthcare provider.

Patient with insurance that is not in our network are responsible for the entire cost of the visit. You will be required to pay $100.00 prior to seeing the healthcare provider. You will be billed on the next billing cycle for any remaining balance.

There is a $25.00 fee for returned checks.

If you fail to keep your medical appointments, you will be subject to a $25.00 fee. Missed procedural appointment appointments will result in a $100.00 fee. Missed Mohs appointments will result in a $250.00 fee. You will be unable to schedule appointment until the missed appointment fee is paid in full.

We will keep your credi card information on file securely offsite.

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.

Your information will be encrypted.