Unless other arrangements are made, payment for visit is due at the time of the service
(either full fee if you are paying privately, or your co-payment if we are billing your insurance company).
Insurance is billed as a service to our patients. I understand that all charges not paid by my insurance carrier(s) remain my responsibility. Office staff is available to discuss potential payment issues with you.
Twenty-four hour notice is required for a cancellation of scheduled appointments. You may be subject to a charge of the following fees for appointments that you “no show”: No show fee is $50.00.
You are at risk of losing your privilege to receive care at Shenandoah Dermatology if you “no show” for two consecutive appointments.
Please review the following:
I understand the insurance may be filed for me, but I am ultimately responsible for payment of fees regardless of insurance coverage. I authorize the release of medical information required to process insurance claims and/or to complete Treatment Plans/Reviews as requested by insurance or managed care companies.
I understand that Shenandoah Dermatology accepts payment by cash, check or credit card, including Care Credit.
I authorize payment for my insurance company to be made directly to the practice.
I understand that I am responsible for obtaining proper (pre)authorization from my insurance company if necessary. I accept responsibility for payment if authorization is not obtained.
I understand that I may be billed for any missed appointments unless I cancel at least 24 hours before my scheduled appointment. Charges for “no shows” are NOT covered by the insurance company.
I understand that mailed monthly bills are due at the time of receipt. Any bill not paid will be turned over to a collection agency, unless other arrangements have been made. If my account becomes assigned to a collection agency, I agree to pay all cost of collection, including $30 collection fee, court costs and attorney fees.
I agree that, in order for Shenandoah Dermatology to service my account or to collect any amounts I may owe, Shenandoah Dermatology may contact me by telephone at any telephone number associated with my account. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, text or email, as applicable.
Social security numbers are required for billing purposes in our office. I understand that if I choose not to disclose my social security number there will be a $75 charge due prior to treatment in the office. After insurance processing, I understand that I will be refunded any applicable credits.
*If patient is a minor, parent/legal guardian must sign and we must have the guardian’s SSN.
I hereby give my permission to disclose personal health information about my treatment to the following individuals: (Example: Spouse, parent/legal guardian, friend, etc.)