Financial Policies

Please correct the errors described below.


It is your responsibility at the time of service to provide our office with:

  • All information that applies to the primary insured including date of birth and social security number
  • The insurance claim submission address(es) for your insurance plan(s)
  • The copayment as required by your insurance company

Referral Policy

For plans requiring referrals for coverage: you must present a valid referral, coordinated by your primary care physician, prior to service to qualify for your insurance benefit. If you do not have one:

  • You may reschedule your appointment
  • You may choose to be seen without the referral but understand that any charges resulting from this visit will be your responsibility; as per your contract with your insurance carrier, you have agreed to bring a referral to be treated by a specialist. A $100 deposit toward the cost of the visit will be required prior to being seen; this will be refunded if a referral is received within the timeframe allowed by your insurance company.

For plans requiring referrals for a maximum or optimal benefits (POS or Point of Service plans): a referral may not be required, but it is the responsibility of the patient to be aware of his or her insurance benefits. If you choose to be seen without a referral you will be responsible for all copayments, deductibles, coinsurance or other charges as per your contract with your insurance company.

Following Claim Submission

You will be billed for any deductibles, copayments or coinsurance as determined by your insurance company. Payment is expected upon receipt of statement from our office. Occasionally, insurance companies will request information from you regarding medical claims. You must respond to these inquiries within 14 days or you may be held responsible for the entire charge of the medical visit. Unpaid balances will be forwarded to an outside collection agency after 90 days and will incur a 22% collection fee, attorney's fees, and/or court costs in addition to the outstanding balance.

Medicaid Notice

Windsor Dermatology does not participate with any Medicaid plans, including plans administered by private insurance companies. If you have a Medicaid plan, you will be responsible for charges for our services.

Additional Policies and Notices

  • Biopsies and laboratory tests will be sent to an outside laboratory. These services may incur additional expenses that are the patient's responsibility based on their medical benefits. These may be billed separately by the laboratory.
  • Hair loss may be considered cosmetic by your insurance, and you may be responsible for charges including related lab tests.


In accepting our care, you agree to pay for services at the time of your visit.


Windsor Dermatology requires all patients to provide a credit card to be kept on file, which will be encrypted and stored securely. In providing your credit card information, you give Windsor Dermatology permission to charge the card on file for your copay(s), coinsurance, and/or outstanding balance(s). If your insurance provider has paid its portion of your bill and there is still a balance due, Windsor Dermatology will mail one statement. If the balance is not paid within 30 days, Windsor Dermatology will provide a courtesy phone message or email prior to charging any balance owed by you to your credit card. A copy of the charge will be mailed to you. This in no way compromises your ability to dispute a charge or question your insurance company's determination of payment.


Cosmetic procedures are not covered by your insurance plans and you will be responsible for payment at the time of service. Your provider will notify you if a procedure is cosmetic and the cost of the procedure before the service is rendered. These charges are independent from any charges associated with medical services covered by medical insurance.

Scheduling and Cancellation Policies for Cosmetic Visits:

  • A charge of $100 will be placed on the credit card in file for cosmetic appointments that are missed or that are cancelled less than 24 hours in advance.
  • If the fee collected from a cosmetic consultation is to be credited towards payment for that procedure, then that procedure must be performed within 6 months. Beyond that period, the credit is forfeit, and repeat consultation may be required.

I am aware of, have read the above, and accept the financial policies of this office as indicated by my signature below.

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.


I authorize use of this form on all my insurance submissions, as well as then release of information to all my insurance companies allowing my provider to submit claims and receive payment for benefits covering services rendered for myself or dependents. I permit a copy of this authorization to be used in place of the original and understand that I am financially responsible for all charges as per my agreement with my insurance company and this office.

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.