Thank you for choosing DayStar Skin and Cancer Center for your medical care. We appreciate that you have entrusted us withyour healthcare and we are committed to providing you with the best patient care possible.
Because healthcare benefits and coverage options have become increasingly complex, we have developed this financial policy to help you better understand your responsibilities as a patient. We will do our best to assist you with understanding your proposed treatment and in answering questions related to submitting your insurance claim for reimbursement.
Your health insurance policy is a contract between you and your health insurance company. Please note it is your responsibility to know if your insurance has specific rules or regulations, such as the need for referrals and/or pre-authorizations. You should be knowledgeable of any deductibles, copayments and/or coinsurance.If you are uncertain about your current health insurance policy benefits you should contact your plan to learn the details about your benefits, out-of-pocket expenses, and coverage limits.
Please provide us with your current insurance card at the time of each visit and notify us of any changes. We will request a copy of your insurance card to copy and keep on file for our records.
Please be aware of and provide any required referrals or authorizations in advance of the appointment. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt, contact your plan directly for clarification.
Our doctors belong to many insurance plans. Before your appointment, please be sure your doctor is in-network and the services are covered under your plan. If your doctor is out-of-network, you will be billed for the costs of care. We will help you find out if you have out-of-network benefits and submit a claim to your plan on your behalf.
You are expected to pay your co-payment and any co-insurance and/or deductible amounts, if known, at the time of service. We accept cash, personal checks, VISA MasterCard, and Discover.
You may receive Pathology services during your visit and there will be additional charges for these services.
Self-pay patients are required to pay 100% of the estimated amount due at the time of service.
Additional fees may apply to the following:
Returned Checks – There will be a $25 fee assessed on returned checks.
Missed Appointments – We require a 24 hour notice of appointment cancellation. Appointments missed that are not previously cancelled will be charged a fee of $25.
Late Arrivals - A patient who arrives more than 15 minutes after his/her appointment is considered a late arrival. A late arrival, not considered to be the responsibility of the Practice, will be registered and worked into the schedule as soon as possible. If the patient is more than 30 minutes late, the appointment may be rescheduled.
Assignment of Benefits and Responsibility to Pay
I hereby assign all medical and surgical benefits to which I am entitled. I hereby authorize and direct my insurance to issue payment directly to Daystar Skin and Cancer Center for medical services to myself and/or my dependents. I have also read and understand the financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.
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.