By scheduling to be treated at Dermatology Solutions you are agreeing to office consents and financial policies outlined below. Official consents will be obtained at your first visit and may be updated annually in compliance with all state and federal laws, rules and regulations.
By signing this document, I am agreeing to the terms of this Financial Policy.
PAYMENT AT TIME OF SERVICE: Payment is due in full at the time of service unless you are covered by Medicare or an insurance company with which we participate. We accept cash and credit cards. We do not accept checks.
INSURANCE: Patients will be asked to present their insurance card to the receptionist for copying upon each check-in. Dermatology Solutions is required by contract with commercial insurance companies as well as government health programs to collect any copayment, co-insurance and any unmet deductible at the time of service. We will file your insurance claim to the insurance company, and any charges that are not paid by your insurance company are your responsibility. Your insurance policy is a contract between YOU and your insurance company. Any referrals, prior authorizations and pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service and we will file your claim to the insurance company as a courtesy.
The amount collected at the time of service is an estimate based on benefit information available. Specific benefit amounts are unavailable until claims have been filed and/or processed by the companies. Your credit card will be kept on file to process any refunds or remaining balances. Once your credit card information is entered, it is encrypted and cannot be viewed or accessed by anyone in our organization. Square, CardConnect and Chase are registered with Visa, MasterCard, and American Express and independently certified as a PCI-DSS Level One Service Provider. Patient portion is adjusted and refunds/amounts due are reflected in patient account after claim processing is complete.
IF INSURANCE CARD IS NOT PROVIDED ON/BEFORE DATE OF SERVICE:
Your signature signifies that you clearly understand that without a current copy of your insurance card, the following situations may be applicable:
We cannot verify whether or not we are in network/participating with your plan.
We cannot verify whether or not a referral is needed for your visits.
We cannot guarantee that the insurance claim will be submitted to the carrier within their filing limit deadline.
This may result in your being responsible for all charges incurred on this date of service.
By signing below, you certify that you understand the above and still want to receive services from our office today.
COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency.
CONSENT: I hereby authorize Dermatology Solutions to file claims and appeals on my behalf, and on behalf of my dependents, and to receive benefits directly from my insurance company, Medicare and/or supplemental policy. I also authorize the release of any medical information to my insurance company, Medicare and/or supplemental policy that is necessary for the processing of claims. I understand that my signature will remain on file for timely submission of insurance claims and for release of my medical information to my insurance company, Medicare and/or supplemental policy.
I certify that the information given by me in applying for Insurance and/or Medicare payment is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my Insurance and/or Medicare benefits, and I authorize payment of these benefits to Dr. Sanober Amin on my behalf for any services and materials furnished. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer of agency shown, and authorizes my doctor to act as my agent, as above.
Cancellation and Late-Show Policy
I acknowledge that I have received, read and understand the Cancellation and Late-Show Policy. This policy requires that I contact the office via phone, email or text message at least 24 hours or one business day prior to scheduled appointment to cancel or reschedule or I will incur a $25 cancellation fee for medical visits, and $100 fee for cosmetic visits. Additionally, if I am more than 15 minutes late for my appointment, I may be asked to reschedule my appointment. Certain types of appointments and procedures may require a deposit, which may be applied towards the cancellation fee if I fail to cancel within 24 hours or one business day.
Treatment Compliance Policy
I acknowledge that I am not eligible for refills of any topical, oral or systemic medications in the event that I miss or cancel my appointments. Some treatment plans require regular clinical or lab monitoring for development of side effects, some with serious consequences, so follow ups are scheduled to ensure that my treatment plan is effective as well as safe.
Cosmetic Services and Retail Products
Dermatology Solutions will charge in full for cosmetic services and products at the time of service. Unless defective due to manufacturing errors, I understand that there are no exchanges or refunds on cosmetic retail products.
Audio and Video Recording Policy
I acknowledge that to maintain confidentiality and privacy of other patients, visitors, staff and physicians at the practice, I am strictly prohibited from using any audio or video recording devices, including but not limited to cameras, cell phones, portable audio or video recorders or recording apps, on the premises of Dermatology Solutions, including in the exam rooms. I will turn my phone off or on silent mode while in the exam room.
Medical Records
I acknowledge that there is a fee for obtaining copies of my medical records, as allowed by state regulations: $20 for the first 100 pages, and for each additional 100- pages.
Referrals
I understand that it is my responsibility to obtain any primary care referrals, and prior authorizations and pre certifications for visits and procedures, as required by my insurance. Failure to obtain these in a timely fashion may result in denial of payment on insurance claims. In that case, I will be responsible for payment of my balance at Dermatology Solutions.