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In Case of Emergency

With my consent, DermCARE Practitioners, LLC may use and disclose protected health information (PHI) about me, including diagnosis, records, examination rendered to me, and claims information, to carry out treatment, payment and healthcare operations. You have the right to review our notice before signing this consent. We encourage you to read it in full. It is available at the front desk or online at www.DermCAREPractitioners.com/new-patient-forms .

By signing this form, I understand that:
• Protected health information may be disclosed or used for treatment, payment or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The patient has the right to revoke this consent in writing at any time.

DermCARE Credit Card on File / AutoPay Policy

The following financial policies are in place as of January 1, 2025:

All new patients making an appointment are required to place a credit card on file with our office. This card will be used for no-show fees ONLY. Patient balances will not be charged to the card automatically unless you opt into our Autopay services described below. Our No-Show fee is $50. No further appointments will be scheduled until the charge is paid. This fee is not filed with your insurance carrier; it is the direct responsibility of the patient.

All cosmetic services patients require a credit card on file at the time they are scheduled.

For cosmetic procedures, a $100 no-show fee will be charged (e.g. micro- needling, chemical peels).

A $50 fee will be charged for injectable appointments in the event of a no- show (e.g. ‘tox, filler).

Any patient who has had their account at DermCARE turned over to collections will be required to have a card on file AND enroll in Autopay before being scheduled for future appointments. AutoPay information is below.

Patients that accrue ONE or more no-call/no-show events will be required to have a credit card on file to be used for future missed appointment fees.
Your credit card information is protected.

We use the same methods to guard your credit card information as we do for your medical information. The card information is securely protected by the credit card processing component of our PCI and HIPAA compliant practice management system. Your card information is encrypted and once in our system, only the last four digits are seen by our staff. There is no way to export the card information out of our system.

Having a credit card on file does not automatically enroll you in AutoPay for balances due after insurance processing. You must opt in to AutoPay for payments to be automatically processed.

What is AutoPay:

Your credit card on file with us will be used to automatically process your account balance after insurance has been filed and applied to your account.

The remaining amount is the patient balance, and we will notify you THIRTY days in advance of any pending charges to your card on file. This policy in no way compromises your ability to dispute your charge nor question your insurance company’s Explanation of Benefits.

Please contact us in advance if you have any questions or concerns about your remaining balance. You can contact our billing office at 502-546-6600 to discuss.

• Payment is required at the time services are rendered unless you are covered by an insurance company with which DermCARE Practitioners participates.

• We accept payment in the form of cash, check, or credit/debit card.

• I understand that it is my responsibility to present accurate, current insurance coverage information at the time of check-in.

• I will be asked to pay for all services not covered, deductible amounts, co-pays, past due balances, as well as balances due resulting from invalid insurance information.

• IF A REFERRAL IS REQUIRED, I will be held responsible to obtain and present this referral prior to my visit. If this is not provided at the time of my visit, services provided will remain my responsibility.

• I understand it is the policy of DermCARE Practitioners to collect any outstanding balance before additional services are rendered.

• Claims not paid by your insurance carrier within 90 days will be considered a non-covered service.

 

RETURNED CHECKS:

There is a $25 fee for any returned checks

INSURANCE INQUIRIES:

From time to time I may receive a letter from my insurance company requesting information about my coverage. I understand that claims will not be paid without  providing this information. I will reply to all insurance inquiries within 30 days of receipt or the balance will become my responsibility to pay.

• Failure to provide 24 hour notice will result in a no-show/same day cancellation fee and will be collected to the extent permitted by law or applicable payor contracts. For your convenience, we offer two appointment reminders prior to your appointment that will allow you to cancel at that time. However, it is ultimately your responsibility to keep track of your appointments whether you receive a reminder call or not.

• If you miss an appointment without a 24-hour notice or if you cancel the same day as your appointment the following fees may be assessed to your account.
  • $50.00 for medical appointments and injectable appointments (botox and filler).
  • $100.00 for cosmetic procedures appointments (Microneedling, chemical peels etc.).

• If you arrive more than 10 minutes past your scheduled appointment time, you may be rescheduled so that other patients are not inconvenienced.

• Patients with multiple cancellations or missed appointments may be discharged from our practice.

Your insurance company may deem certain procedures as not medically necessary, or cosmetic. If you and your doctor/provider decide to continue with a procedure that falls into this category, we require payment in full at the time of service. The following are some examples:

• Skin tags, angiomas, sun spots or liver spots, cysts, milia, sebaceous hyperplasia, or seborrheic keratoses, etc

• Botox, fillers such as Restylane, scar revisions, cosmetic consults, or cosmetic procedures such as chemical peels and microneedling, etc.

THE COST OF THESE PROCEDURES WILL BE A SEPARATE FEE FROM AN OFFICE VISIT.

ACCOUNT BALANCES All balances are due in full within 30 days of my first billing.

 

It is my responsibility to contact the office to arrange for an acceptable payment plan should I be unable to pay my balance in full.

 

If my balance is unpaid after 60 days, I understand I will incur a $25.00 administrative billing fee.

 

Any balance left unpaid after 90 days will be sent to GLA for collections, I understand I will be responsible for an additional 30% administrative collection fee plus any attorney / court fees which may be added to my account during efforts to obtain payment.

A debit/credit card on file and a deposit of $50 will be required prior to office visits for any patients who have had their DermCARE account turned over to a collections agency.

All account balances must be paid in full in order to schedule any future appointments.

• I hereby consent to the medical and surgical care and treatment, as may be deemed necessary or advisable in the judgment of my health care provider.

• If I am concerned about the cost associated with treatment, it is my responsibility to request a procedure estimate prior to starting treatment.

• Since each insurance company has its own policies regarding the coverage of procedures, I also acknowledge that I am responsible for payment in full for the charges incurred for procedures regardless of the coverage provided by my insurance carrier.

Pathology Studies and Laboratory Tests:

• Our bills for service do not include pathology studies or laboratory tests. YOU WILL RECEIVE A SEPARATE BILL FROM THE PATHOLOGIST OR LABORATORY FOR THESE TESTS.

• If your insurance plan has a preferred provider for blood work, please notify our office staff prior.

• Although the lab will file with your insurance, you are responsible for any bill you may receive from the laboratory or pathologist. Please discuss any billing errors or discrepancies with those institutions.