Patient Financial Responsibility Form

Disclosure Statement

Please correct the errors described below.

In order to establish optimal relations with our patients and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to consistently inform you of the financial payment policies of this office. Payment is required for all services at the time they are rendered unless you are in a prepaid plain in which we participate. WE DO NOT BILL PATIENTS. Payment for cosmetic products will not be billed under any circumstances.

As a courtesy to you, we will file to a participating insurance company for services our medical providers rendered today. Once payment is received is received we will adjust certain balances according to our contracts with your insurance carrier. If we do not have a contract with your insurance carrier, you will be responsible for payment at the time of service. Should we receive payment from your insurance company, you will be refunded in a timely manner. You are considered a cash patient until you bring in completed forms, and this office qualifies and accepts your coverage.

For those patients, applicable co-payments and deductibles will be collected at the time of visit. WE DO NOT BILL PATIENTS FOR DEDUCTIBLES OR CO-PAYS. We accept payment in the form of cash, check, or credit card. In the event of hospitalization or major procedures, our office may file a with the appropriate insurance. However, before such claims are filed, coverage will be verified and you will be asked to pay any remaining deductible, non-covered services and co-payments. In the event that your check is returned a $40.00 fee will be added to your account. Your initial signifies your understanding and willingness to comply with this policy.

I an responsible for providing a copy of my current insurance card to the Hecker Dermatology Group, P.A. office upon every visit. If my current insurance information is not presented, it will be my responsibility to file with the proper insurance company and pay Hecker Dermatology Group, P.A. in full for services provided.

You are responsible for taking an active part in the recovery of your insurance claim. After 45 days, you will be responsible for payment in full for any outstanding balance. After 45 days, you authorize us to use your personal credit card to collect payment in full. In addition, any account over 45 days or more past due will incur 1.5% per month in additional fees from the date or services.

If I do not make payments, and my account is sent to an external collection agency, I understand and agree that I will be responsible for all charges incurred by Hecker Dermatology Group, P.A. from it’s agent (including, but not limited to legal fees) in order to collect on the debt. Your initials signify your understanding and willingness to comply with the above policies.

Written acknowledgment of Notice of Privacy Practices. I have reviewed/received a copy of the notice of Privacy Practices of Hecker Dermatology Group, P.A. or have been offered a copy, but declined to accept a copy.

It is our policy to keep a copy of a credit card on file for outstanding balances. This is a result of increasing difficulty with collections. Your credit card will only be charged after 45 days if the patient’s portion of the medical bill is not received (I.e. co-pay, deductible, etc.) We will not bill for any portion of the charges that is covered by your insurance. The physician will only be able to see you with a credit card on file. At the time of appointment, please provide the front desk with your picture ID, insurance card(s), and a major credit card.

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.

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