Thank you for choosing Acclaim Dermatology, PLLC and Syed O. Ali, M.D. as your health care provider. It is our goal to meet patient needs and address patient concerns effectively. Areas of primary concern for all patients are the financial policies of the practice, especially those pertaining to insurance billing and patient payment requirements. As in all aspects of healthcare today, the greater role the patient assumes in the healthcare process, the higher the degree of satisfaction achieved. For that reason, we expect our patients to take an active role in their healthcare management, including the area of finances. In an effort to keep patients informed about such policies, we ask that all patients read and sign a copy of our Financial Policy prior to receiving treatment.
PAYMENTS are expected at the time services are rendered. This includes all deductibles, co-insurance, co-payments and any non-covered services, such as cosmetic procedures. Patients who have an insurance carrier with whom the practice has a valid contract will be responsible for all fees as outlined in the patientsʼ contract agreement.
INSURANCE is filed for all insurance carriers for whom the practice has a valid contract. The patient is responsible for filing claims for carriers for whom the practice does not have a valid contract. This includes all carriers who are secondary to Medicare. It is the insuredʼs responsibility to verify that the services requested and the physician is covered by the terms of your insurance plan. If there are any questions the insured is to call his/her insurance carrier to confirm coverage. If any services are denied as out of network, not covered by the terms of the policy, policy not in force, not medically necessary, or have a deductible/co-pay issue, the patient or responsible party will be billed.
PATHOLOGY is ordered by our physician to properly diagnose certain skin disorders. The analysis of these specimens is performed by a board-certified dermatopathologist who specializes in the microscopic diagnosis of skin disorders. Our dermatopathologist is in-network for the insurance plans for which we are contracted. Please note that if any of these services are denied as out-of-network, not covered by the terms of your insurance policy, as requiring a deductible or co-payment, or other related issues, the patient or responsible party will be billed.
RETURNED CHECKS will result in a $25.00 service charge. The check amount plus the service charge is to be paid within 10 days of notification. Failure to pay in full in 10 days will result in collection through the appropriate means.
CANCELLATION POLICY: If you are unable to attend an appointment, please let us know as soon as possible, preferably 24 hours prior to your appointment time, so that we can assign your time slot to someone else. If you do not do so, we reserve the right to charge the following “late cancellation or no-show fee”
$35.00 for an office visit
$100.00 for a procedure visit (surgery)
$150.00 for a cosmetic appointment
As a courtesy, we make every effort to call to confirm appointments in advance; however, it remains YOUR responsibility to know and to keep your appointment. We realize that emergencies arise and will be considered on an individual basis.
Requests for Medical Records
REQUESTS FOR MEDICAL RECORDS: A charge of $25.00 will be incurred. Upon receipt of payment, the requested documentation will be available or can be picked up within 3-5 business days unless otherwise notified.
Statements and Billing Correspondence
STATEMENTS AND BILLING CORRESPONDENCE are sent only when you have a balance on your account. They will show whether your insurance company has fulfilled their obligation to you, the policy owner, to pay claims in a timely manner. Statements will show insurance payments and your remaining balance.
DELINQUENT ACCOUNTS are referred to a collection agency and reported to the credit bureau. Patients having financial difficulties are encouraged to discuss them frankly with our Office Administrator before the account becomes delinquent.
CREDIT CARDS are accepted for payment. We accept VISA, MasterCard, Discover and American Express.
I have read the Financial Policy of Acclaim Dermatology, PLLC and understand and agree to adhere to the policies as outlined. I further agree to be responsible for all charges not covered by the terms of my insurance plan, or in the case of cosmetic treatments for all charged incurred.
DISCLAIMER: 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.