FINANCIAL POLICY FORM
Thank you for choosing Dermatology Center of North MS, P.A. for your dermatology needs. We are committed to providing you with quality medical care, our professional fees have been determined through careful consideration, and we believe these fees are reasonable and reflect other area physician's charges. We are pleased to discuss with you any questions you may have concerning your bill. Providing quality care is our primary concern.
PRIVATE INSURANCE POLICIES: Dermatology of North MS, P.A. will file claims directly with your insurance carrier for services where covered benefits have been verified. Insurance verification does not guarantee your insurance will pay for services. Payment of co-insurance, co-pays, deductibles or fees for non-covered services, when applicable, is required at the time of service.
CONTRACTED MANAGED CARE PLANS (HMO, PPO, ETC): Each time you make an appointment with a Dermatology of North MS, P.A. physician, it is your responsibility to make sure the physician is currently under contract with your plan and you have obtained the necessary referrals when needed. Verification of your plan benefits/coverage is required. Often this verification requires us to share the reason for your visit with a managed care plan. Payment of co-insurance, co-pays, deductibles or fees for non-covered services, when applicable, is required at the time of service.
We allow 45 days from the date a claim was filed by our office for the insurance company to pay. If the Insurance Carrier has not paid within this time, you are responsible for the entire balance. We will not become involved with disputes between you and your insurance company regarding deductibles, non-covered services, co-insurance, co-payments, coordination of benefits, pre-existing conditions or "reasonable and customary" charges other than to supply factual information when necessary. You are responsible for the timely payment of your account.
MEDICARE TRICARE/CHAMPUS: Dermatology Center of North MS, P.A. does not accept assignment of Medicare Tricare/Champus benefits. You may be asked to sign a waiver to acknowledge your understanding of your responsibility to pay for services not covered by Medicare Tricare/Champus.
MEDICAID: Dermatology Center of North MS, P.A. is not a contracted provider for services for Medicaid only.
MEDICAL/SURGICAL PROCEDURES: I understand that the pricing that is given by the staff of Dermatology Center of North MS, P.A. is an estimate and that there could be additional cost once the claim has been processed by my Insurance Carrier. If processed and is less, a credit will be issued to the account or refunded when requested.
METHOD OF PAYMENT: For your convenience, Dermatology Center of North MS, P.A. will be happy to accept your personal check, cash, Visa, and MasterCard for payment of your medical services. A $35.00 fee will be accessed to your account for all returned checks.
MINORS: The parent(s) or guardian(s) of a minor are responsible for providing current insurance information for the minor and/or payment in full for services provided. Unaccompanied minors must have authorization for medical treatment signed by a parent or guardian and is responsible for current insurance information for self and/or payment in full for services provided
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 have read and understand the above terms and conditions and will verify so by giving my signature.