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.