Unpaid account balances will be assessed a $10.00 re-billing fee for each
statement generated after 90 days passed. Late fees will begin accruing after 90 days.
If your account is overdue for more than 120 days after your insurance has paid, it will be
referred to a collection agency. This is done reluctantly, as a last resort, after we have
exhausted all efforts for voluntary payment.
New Patients, and those who have no insurance, are required to pay at the time of service
with either a credit card or cash. We do not accept personal checks.
Acknowledgement and Authorization
I have read, understood and agree to abide by the above payment policy. I understand that charges not covered by my insurance company, as well as copayment, deductibles and coinsurances, are my responsibility.
One-Time Authorization for Recipients:
Irequest that my payment of authorized Medicare benefits be made to me on my behalf to Michael T. Lin MD., Inc for any services furnished to me. I authorize holders of medical information about me to release to the Centers for Medicare & Medicaid Services and it's agents any information needed to determine these benefits or the benefits payable for related services. Additionally, I request that payment of authorized Medi-gap benefits be made to either me or on my behalf to Michael T. Lin MD., Inc. for any services furnished by this provider. I authorize any benefits or the benefits payable for related services.
By signing below, you agree to the Terms and Conditions of Advanced Dermatology and Skin Cancer Institutes Payment Policies: