FINANCIAL RESPONSIBILITY - I understand that although Ginsburg Dermatology Center will file a claim to my insurance plan(s), I am expected to pay my copayment, coinsurance, deductible, and non-covered services amounts at the time services are rendered. Because insurance policies vary greatly, we can only estimate the portion due in good faith. I acknowledge that Ginsburg Dermatology Center does not guarantee payment of my claim by my insurance plan and that it is my responsibility to know the provisions of my insurance. Not all procedures are deemed “Medical Necessity” by insurance carriers and can be considered cosmetic. For example-Skin, tag removal, correction of dark spots, yearly skin cancer screenings without specific areas of concern would not be a covered service. I understand I would be responsible for the payment of such services. I am ultimately responsible for any unpaid balance or non-covered service. I agree to pay all costs of collecting, securing, or attempting to collect or secure payment, including reasonable attorney fees or collection agency fees. I also understand any prior unpaid balances on my account must be paid in full before being seen by the provider. If my prior balance cannot be paid in full, I will speak with the billing department at Ginsburg Dermatology Center to make a payment arrangement before services are rendered. I also understand that if Ginsburg Dermatology Center does not participate with my insurance plan that, I will be expected to pay in full for my services. And it is my responsibility to know if Ginsburg Dermatology Center is in-network with my insurance plan. I understand that payments to Ginsburg Dermatology Center can be made by cash (please use correct change), checks, and all major credit cards. I also acknowledge that returned checks will be subject to a non-sufficient fund fee of $25.00.