Financial Policy: The following is a statement of our financial policy, we require you to read and sign prior to treatment. In the event that you have a question regarding treatment fees, please discuss them with us promptly. We will make every effort to avoid a misunderstanding.
If your insurance carrier fails to pay your claims within 45 days from the date of service the balance will become the patient’s responsibility. Regardless of insurance coverage, you are responsible for your account to be paid in a timely manner. Please be aware some and perhaps all of the services provided may be considered “non-covered” services and are not considered reasonable and or necessary under your policy. These services will be your responsibility to pay. Kindly note that your insurance policy is a contract between you and your insurance company; we are not a third party to that contract and cannot be responsible for their failure to timely pay for services rendered. Treatment fees will be billed to the insurance company separate from an office visit. In the event that the treatment is not covered under the patient’s insurance plan, the patient will be responsible for payment to be made promptly. Some treatments (i.e. Cryotherapy) may require multiple office visits in which the insurance company will be billed for the services rendered at each visit
Plastic Surgery and Dermatology Associates will submit to those insurances that we are participating providers with. If we do not participate with your insurance you are expected to pay at the time of service. You may seek reimbursement from your insurance carrier. Reconstructive Plastic Surgery Consultants is a provider with Medicare and Tricare Standard, claims for all other insurances will be processed under your out of network benefits if available for medical services.
Payment in full is required prior to the procedure being performed. Prepayment time frame will vary depending on the procedure. Payment arrangements will be made prior to scheduling. Cosmetic procedures are not billed to your insurance company.
Appointments for accidents or injury claims involving litigation: The person who receives the care is the one responsible for the account. You are required to make payments on the charges even if they will be covered by a third party. You will promptly be reimbursed any fee that you have paid, if and when we are reimbursed by the third party.
Accounts that are delinquent will be submitted to an outside collection agency which may result in court actions. Signing this document states that you and or the responsible party acknowledge that you allow our collection agency to contact you by phone/cell in accordance with the Telephone Consumer Protection Act, as well as, are responsible for any and all collections cost/attorney fee, service fees and court fees associated with the collections of outstanding balances on the account
In the event your check is not honored by your bank, there will be a fee of $40.00 access to your account. You are required to pay this fee as well as the service fee to avoid being referred to collections.
A fee of $0.50 per page plus an administrative/postage fee of $10.00 will be charged for the release of information. Records will be released once payment has been received.
Appointment Cancellation/ No Show:
Patients who fail to call 48 hours prior to the appointment date will be billed a cancellation fee. There is a $40.00 no show/ cancellation fee for office visits. There is an $80.00 no show/cancellation fee for office procedures or for appointments scheduled for greater than 30 minutes. Although we do our best to do a courtesy reminder call, it is the patient who is responsible to remember the date and time of their appointment.
Product purchases are final sale, there are no returns, exchanges or refunds given for products
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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.