JASON B. AMATO, MD DERMATOLOGY

1. Information: In order to establish optimal relations with our patients and to avoid any misunderstandings regarding our financial policies, our staff is trained to inform you of the financial policies of this office. If there is any part of our financial policies that needs clarification, please feel free to ask one of our patient coordinators or our billing staff.

2. Insurance: We will file your medical claims with the your insurance carrier if we participate with that plan. It is the responsibility of the patient to provide accurate insurance and personal information including any preferred laboratory needs. If your insurance requires a referral, it is your responsibility to provide the referral prior to your visit. You will be responsible prior to your appointment for the payment of any copays and all balances due from previous appointments. You authorize this office to release any necessary medical information to process your insurance claim. You herein authorize payment of medical benefits to this office when an assigned claim is filed with your insurance company.

3. Self-pay and cosmetic: Payment is expected in full at the time of or prior to the service.

4. Cancellation and Missed Appointments: We work hard to try to offer timely appointments for our patients. / understand that it is my responsibility to cancel my appointment greater than 24 hours in advance of my appointment. This allows us to offer the appointment to other patients who are waiting to get into the office. For a cancellation within 24 hours of the appointment or a "no-show," a $75 fee (for a routine appointment) or a $150 fee (for a surgical or cosmetic appointment) will be billed to my account. This fee, which is not covered by my insurance plan, is the responsibility of the patient or guardian.

5. Requests for medical records: Available at a fee dependent upon chart volume. Medical records may be sent to another provider at no charge.

6. Methods of payment accepted are: For your convenience, we accept Mastercard, Visa, Amex, Discover and personal checks with proper identification (valid Driver's license or photo ID If your check is returned to us as unpaid, a $50.00 overdraft charge will be added to your balance due.

7. Credit card on file: Jason B Amato MD Dermatology will securely store an updated credit card on file for all patients with commercial (non-medicare) insurance. In addition, we will keep a credit card on file for all cosmetic patients. This information is stored securely with Square. Should you have a balance once we file with and hear back from your medical insurance company, we will send you an invoice for the balance that is due either by email, text, or mail. This balance is due 30 days from the date your insurance company informs us electronically (and you through their Explanation of Benefits) of any balance due to our office. Any balance remaining after 30 days of this notification date will be charged to the credit card on file. This policy will avoid the need for our office to inundate you with multiple mailings and phone calls, avoid any additional late fees, and prevent us from sending your account to collections should we be unable to get in touch with you. Should you

JASON B. AMATO, MD DERMATOLOGY

choose not to allow us to keep a credit card on file for balances due, we will ask for a "deposit" payment based on and prior to services rendered. Once we file with your insurance and they inform us of the amount of the claim that is the patient's responsibility, any part or all of the deposit that is not part of the patient responsibility will be returned to the patient or guardian within 30 days from the date we hear from your insurance.

8. Patients under 18 years old: The policy of this office is the parent or guardian who accompanies the minor patient is responsible for all fees as outlined above including copays and outstanding balances prior to the appointment. Only the parent or guardian who accompanies the minor patient will be billed for balances due after filing with their insurance.

9. Agreement: By signing this form you authorize Jason B Amato MD Dermatology to bill your card on file as described above. Receipt of any transaction will be forwarded to the email address given. By signing you agree that you have read, understand and abide by our stated financial policies. You also understand that failure to make payment when due is the basis for further action and agree to pay all costs of late fees. This includes any fees added should your account be turned over to collections, including court costs and attorney fees.