FINANCIAL RESPONSIBILITY STATEMENT
Insurances are becoming increasingly more difficult to understand. All policies differ, even between persons under the same carrier. Therefore it is your responsibility to know your policies limitations. Our office can make no guarantees of your insurance’s payment obligations. This is particularly true when it comes to: hair loss, warts, acne surgery, excessive sweating, injection of acne cysts, or skin tag removal. Commonly patient's seek our opinion for hair loss or wart treatment only to find out their insurance policy does not cover such a visit. Please contact your insurance if you are concerned your issue may not be covered by your policy prior to your appointment as you will be billed for a consultation at a self pay rate.
If we participate or are contracted under a commercial insurance in which you are covered, we will bill the carrier for all charges for all medical services rendered. We will also bill secondary insurances when applicable.
Your responsibility at the time of service will be:
a. The annual unmet deductible* (as dictated by your insurance)
c. Charges for non‐covered or cosmetic related services/treatments
*Your deductible & copayment are dictated by your particular insurance agreement.
Ultimately, it is your responsibility to know if your insurance policy is active and your benefits under your policy. (i.e., which services are covered, need prior authorization, etc. as this is a privae contract between you and your chosen insurance). Any termination of policy or uncovered or denied services will result in a balance left on your account.
You must present a current active insurance card** and photo ID at the time of your visit.
**If you do not have your insurance card or it is found to be inactive for whatever reason: it will be necessary for you to procure a paper copy from your insurance provider; reschedule; or you can be seen and will be responsible for the charges incurred (deemed “self-pay”). We can provide you with a receipt to submit to your insurance company for reimbursement.
$50 <24 hour cancellation fee/no show- If you are unable to keep your appointment, please provide 24 hour advanced notice so we may give your appointment time to another patient. We make every effort to confirm all appointments 48 hours before your scheduled time. We strive to run on time and do not overbook patients. Therefore no shows greatly affect our ability to see other patients in need. We also reserve the right to cancel your appointment if you arrive greater than 20 minutes late. For your convenience, you may reach us via phone: 305-397-8622 or email: email@example.com. There will be no exceptions.
We reserve the right to deny non-emergent treatment to any person who is not actively making payment or refusing to make payment on delinquent accounts.