Thank you for choosing our practice. We want to make every experience you have with us a positive one. Over the past years, the practice of medicine has become more complicated for physicians and patients alike.
Because of the growing complexity of the insurance business, we feel we can no longer assume that patients fully understand the relationship between the insurance company, the doctor, and themselves. In an effort to clarify this relationship, we have developed a set of guidelines regarding financial responsibility. If you have any questions, please speak with the office staff. You will be asked to sign at the end of the form.
As a participating provider, we accept assignment of benefits and file all Medicare claims for you
Please be aware that Medicare does not pay us the total charges allowed at the time of your visit. You will be responsible for 20% of the total charges at each visit. Furthermore, each calendar year you begin a new deductible with Medicare. If your deductible has not been met for the year, we will ask for payment up to your deductible amount at the time of your visit.
If your secondary insurance plan is part of Medigap (sent electronically by Medicare), your signature will allow us to file claims and assigns to this office all rights, title and interest to your medical reimbursement benefits under your insurance policy.
Medicare sets the fees that we may charge
Any procedures not covered by Medicare (see below) will be identified at the time of service. Medicare does not set the fees for services that are "not medically necessary" and you will be asked to pay for these procedures at the time of service.
Not Medically Necessary or Cosmetic Procedures
In order to keep health care costs down, Medicare has put restrictions on some previously covered procedures. Our office is aware of many of these not medically necessary or cosmetic procedures and will attempt to alert you to these procedures when possible. If you and the doctor decide to continue with a procedures that falls into this category, we require payment in full at the time of service. There is no reduction in fees for Medicare in patients when cosmetic procedures are performed.
The following procedures are routinely considered not medically necessary or cosmetic:
Medicare may not cover these services (including office visits for evaluation of these conditions):
- Removal of benign lesions (moles, warts ,skin tags, cherry or spider angiomas, lentigos or liver spots, cysts, milia and seborrheic keratoses)
- Collagen treatments
- Glycolic acid or other chemical peels
- Ear piercing
- Scar revision
- Laser surgery for certain benign lesions
- Cautery for treatment of dilated blood vessels on the face
- All forms of Hair Loss
- Acne surgery
Laboratory and Pathology Fees
Many times it is necessary to obtain tissue or perform lab tests to confirm a diagnosis or to determine a course of treatment. If any tissue is removed for a pathology examination or if a laboratory test (blood work, culture, etc.) is done in our office, the actual test is usually carried out by someone else. The lab is required to bill with the Medicare for their services. You will receive a bill from the lab after Medicare has paid, and you may be required to pay a percentage of that bill.
If you receive a bill from a lab, please contact that lab directly to resolve any billing concerns.
Forms of Payment
For your convenience, we accept cash, personal checks, Mastercard and Visa.
Estimation of Services
We will be happy to give you an estimate of fees when this is possible. Please, remember that only the
doctor can give you an accurate estimation of the cost of a procedure since he will determine the exact
procedure to be performed. We can only assure you of the exact cost of a procedure on the day of service
when the doctor has determined the actual coding to be used. The estimate of our charges will not include
work done by any outside lab or pathology service.
There is a fee of $40.00 for all returned checks.
We will send you FOUR statements regarding your balance. On the THIRD statement a 1.5% service charge will be added to your balance. If you should receive a FOURTH statement noted “Final” the account balance will be turned over to a collection agency. We will add a 35% transaction fee to any outstanding balance that is turned over to a collection agency. All fees charged are your responsibility.
Please recognize that the practice of medicine is not an exact science and acknowledge that there
are no guarantees or assurances concerning the results of procedures.
By signing below, I am indicating that I do not have a government plan such as MEDICAID or CHIPS or STAR.
I have read and understand the above completely and agree to comply with the financial policies of this office. My signature authorizes this office to file my claims and assigns to this office all rights, title and interest to my medical reimbursement benefits under my insurance policy.
I understand that my signature also allows this office to release information regarding my visits to my insurance carrier. I understand that I am responsible for my bills in the event the insurance company denies any claims.
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.