OFFICE POLICY REGARDING INSURANCES

From prior experience we have come to realize the necessity of this statement in order to anticipate some of your questions and concerns and to outline our billing policy. All patients have the opportunity to obtain a copy of this form upon request.

• Your Cooperation Is Necessary: Without your cooperation, it is virtually impossible for our office to assure that we are informed of the current, specific requirements of your insurance coverage. This is because our office accepts many insurance plans. From time to time, these plans change their requirements for coverage and the scope of that coverage. A single plan may also differ among individuals. Moreover, deductibles, copays and coinsurances vary with each plan and its prior usage.
• Most of Life is Showing Up: Your appointment time has been set aside for you and is unavailable to other patients. Therefore, we require at least 24 hours of advance notice for cancellation for medical ;appointments and 48 hours of notice for cancellation for cosmetic services. If you do miss an appointment or cancel with less than 24/48 hours’ notice, you will be billed $100.00 (medical or cosmetic) or $150.00(surgical!) which must be paid prior to making any other appointments. Appointment reminder calls are a courtesy which we provide. However, if you do not receive such a call, it is still your responsibility to remember your appointment.
• Your Responsibilities: At the time of appointment, it is the responsibility of the patient or guardian to provide our office with whatever documents are necessary for the insurance coverage to be effective. (This is typically just the insurance card and a referral). It is the responsibility of the patient or their guardian to understand how their insurance plan works. The patient or their guardian should understand that liability for full payment remains with the policy holder.
• When Coverage Is Denied: Initial denial of coverage for a procedure by an insurance company is not uncommon. In that case, we will be happy to assist with an explanation of our services for resubmission of claims. If a denial of coverage presents a financial hardship, please discuss this with our Office Manager. The Office Manager is authorized to work with you to implement a payment strategy.
• Typical Limits of insurance: Most insurance, including Medicare, cover 80% of total charges. This only takes effect after the deductible has been met. This practice is NOT expected to absorb your deductible, copay, coinsurance or any other balance of your bill, These are the responsibility of the policy holder. This practice reserves the right to charge finance charges on any unpaid balances. I understand and agree that in the event that I fail to make payment for services rendered to me, my name and account may be turned over to an attorney or collection agency and agree to pay said agency's fees for collection, court costs, and/or reasonable attorney's fees that may be incurred in the collection of any outstanding balance.
• If You Do Not Have insurance: For our patients without insurance, we will charge a flat fee for an initial appointment and for any follow up appointments. These charges are only for the visits. Additional procedures (e.g. biopsies) will have additional fees that will be discussed at the time of the visit and should be paid at that time. For your convenience we accept all major credit cards.
• Biopsies: If you have a biopsy or excision, the specimen is sent to an outside laboratory for tissue processing and sometimes for microscopic examination. We use Bio-Reference and Weill Cornell. We will send them your insurance information. Please be aware that you might receive a separate statement from either laboratory since they are a separate entity. If you receive a bill from either laboratory and have questions regarding the charges, please bring it to the attention of our Office Manager.

I HAVE READ THE INSURANCE OFFICE POLICY STATED ABOVE AND UNDERSTAND THAT ANY AMOUNT NOT COVERED BY INSURANCE IS MY RESPONSIBILITY.

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.