Administrative Policies

CREDIT CARD POLICY OF NWC ESSENTIAL DERMATOLOGY

We thank you for choosing Essential Dermatology, PLLC. We ask all our patients to read and agree to our financial policy. We are happy to answer any questions you may have before you sign this. Unfortunately, patients who refuse to sign this cannot be seen and will be subject to our appointment cancellation policy and fee.

To streamline our billing and payment system, Essential Dermatology, PLLC requires that ALL patients have a valid credit card on file or leave a retainer, even if you have an HSA card. There are no exceptions to this rule. The credit card will be swiped when you check in for your appointment and kept on file. Our office is “PCI-compliant”, which means that we place a high priority on the security of cardholder data.

The credit card shall be utilized only in the event of non-covered services (i.e. services that are not covered by my insurance company), no-show charges, unmet deductibles and copayments.  Prior to using my credit card, Essential Dermatology PLLC and/or its affiliated billing company will invoice the account through mail and/or Patient Gateway, thus allowing me the opportunity to question or dispute the charge. I understand that Essential Dermatology PLLC will only charge my credit card if there is no response to the bill sent to me within a reasonable period (60 days from the first bill). We will NOT contact you first to request your authorization. Your signature below is your authorization.

By signing below, I agree to the Essential Dermatology Financial Policy and authorize Essential Dermatology PLLC to keep my credit card number securely directly stored in the payment system. I allow Essential Dermatology PLLC to automatically charge my credit card for any outstanding balances as outlined above. These may include insurance denials, missed or cancelled appointments, outstanding deductibles, co-insurances, partially paid claims.

If the credit card I provide today changes, expires or is declined, I will provide Essential Dermatology, PLLC with a new valid credit card promptly and/or at the time of the first follow-up appointment. I understand that I am responsible for payment for all medical services provided to me. I understand that this form is valid until I provide a 30-day written notice to Essential Dermatology (220 N Main Street Suite 201 Natick MA 01760) to cancel this authorization. I certify that I am an authorized user of this credit card, and I will not dispute the payment with my credit card company so long as the transaction corresponds to the terms indicated in this agreement.

HIGH-DEDUCTIBLE PLANS: Special Notice

Essential Dermatology, PLLC wants patients to be fully informed regarding the specific benefits afforded to subscribers by their health insurance carriers. Specifically, patients with high deductible plans should take notice of their carrier's policies regarding out-of-pocket costs and deductibles. 

For example, if a subscriber's (a patient's) health insurance plan has a $2000 deductible, before reaching the $2000 deductible, this individual will likely be responsible for ALL charges associated with a given visit to Essential Dermatology per the carrier's policies. With any questions regarding your specific plan's benefits, please reach out to your carrier directly.

No Show/Late Cancellation Fee

I accept that a cancellation fee of $100.00 will be charged for any missed appointment if 24 hours’ notice is not given or for arriving significantly late (> 15 minutes) for my appointment(s), unless acceptable documentation of an emergency is provided.

My signature below affirms that I understand this statement and have accepted responsibility for all fees incurred for my medical care.

As a patient in our practice, we are committed to providing you with:

·       Care and treatment that is safe, thorough and compassionate

·       Care and treatment that is consistent with best practices

·       Attention to your concerns and respect for your preferences

·       Assistance with choosing sub-specialists when clinically appropriate

·       Fair and timely billing of our services

·       Clear, respectful and timely communication, including updates regarding your scheduled appointment times, with you and your caregivers

·       Care and treatment that will not discriminate on the basis of age, race, color, religion, sex, sexual orientation, gender identity or expression, disability, marital status, citizenship, ethnicity, genetic or disease information, or any other characteristic protected by law.

 

As a patient of our practice, we request the following:

·       On time arrival for your appointments

·       At least a one business-day notification of any appointment cancellation, so we can offer the time to other patients in need

·       Informing us of any changes to your health, address or insurance information

·       Prompt payment for your visits

·       Respect and courtesy to our staff and clinical team.

 

The practice reserves the right to terminate the patient provider relationship in the event of a significant deterioration in the relationship.