Alaska Family Dermatology, LLC Patient Financial and Office Policies

Thank you for choosing Alaska Family Dermatology LLC as your health care provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Financial Policy is important to our professional relationship. Please understand that payment for services is a part of that relationship.

Proof of Insurance/Patient Information

Please bring your current insurance card and a photo ID such as a driver's license with you to each visit. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for payment of the charges for services rendered.

Payment for Services

All deductibles, co-payments, co-insurance and past due balances are due at the time of service. Recent shifts in the healthcare industry have resulted in insurance companies increasingly transferring costs to patients. Alaska Family Dermatology LLC has financial policies to enable efficient operational processes. Please see our "Credit Card on File Policy." You are responsible for any balances that may be due as a result of coinsurance or copayments, annual deductible amounts, non-covered services, out-of-network charges, terminated coverage, exhausted benefits, no insurance coverage, and fees related to missed appointments and returned checks.

Insurance Coverage

Insurance is a contract between you and your insurance company. It is the insurance company that makes the final determination of your eligibility and benefits, and it is your responsibility to know your health plan benefits, including co-payment amounts, deductibles, co-insurance, and lab contracts. Alaska Family Dermatology LLC is not responsible for knowing your insurance policy and which services are eligible for coverage and whether services are in-network or out-of-network. It is the patient's responsibility to inform this office if your insurance requires pre-certification or pre-authorization of services prior to scheduling such services.

Our office will bill your primary and secondary insurance company as a service to you. If your insurance company does not pay for any part of the services performed for you at our office, you will be responsible for the complete balance of the non-payable services. If we are out of network with your insurance company and your insurance pays you directly, you are responsible for payment and agree to forward the payment to us immediately.

In order to properly bill your insurance company, we require that you disclose all insurance information to our office, including primary and secondary insurance, as well as any change of insurance information. Failure to provide complete insurance information at the time of service may result in a denial of payment and you will then assume responsibility for all services rendered. In addition, your insurance company may need you to supply certain information directly in order to process a claim. It is your responsibility to comply with their request.

Self-Pay/Non-Insured Policy: If you are a self-pay patient, you will be required to pay your balance in full at the time of service.

Credit Card on File Policy

Recent changes in healthcare markets have altered insurance coverages to shift more of the cost of care to our patients. Many policies have higher deductibles which means, even if a procedure is covered by insurance, you may still receive a bill. These external factors make it necessary for Alaska Family Dermatology, LLC to maintain a credit/debit/HSA card on file for all commercially insured patients. The card information is stored securely with the same HIPAA compliant software that protects your confidential medical information. **Once your credit card information is entered into our payment processing program, it is encrypted and cannot be viewed or accessed by our organization**

Should you have a balance after your visit we will mail out three statements. If no payment is received after 60 days, we will bill the card on file or will pursue other avenues of debt collection which can and will include discharge from the practice and routing to a collection agency. By signing this form, you authorize Alaska Family Dermatology, LLC to bill your card on file. Receipt of any transaction will be sent to the email address on record. If an email address is not provided, the receipt will be mailed to the home address on file.

Non-Covered Services

Insurance plans will generally not pay for the fees associated with removal or treatment of benign skin lesions such as normal moles, angiomas, seborrheic keratosis, and skin tags, among others. If you wish to have a benign skin lesion removed or treated or another diagnosis treated for which insurance does not pay, you accept financial responsibility for any fees associated with the procedure(s) performed.

Pathology/Laboratory:

Skin biopsy samples are routinely sent to a laboratory for microscopic evaluation to determine or confirm proper diagnosis. In some circumstances, a consultation with another laboratory may be requested by your provider. You authorize and understand that you are responsible for the cost of any testing or laboratory services performed and that billing of such services may be billed independently by another physician or laboratory if your insurance doesn't pay or you are a self-pay patient.

Missed Appointments:

Please provide at least 24 hours' notice to cancel an appointment. We do this SO your appointment slot can be offered to another patient in need of attention and that we are able to provide care to those who need it. You will be charged a $50 fee if you fail to keep your appointment or cancel with less than 24 hours' notice. If you do not show ("no show") or cancel for a scheduled procedure (ie. excision) or Patch Allergy Testing and you did not provide our office with at least 24 hours' notice, you will be charged a fee of $150. Payment of any outstanding no-show fees will be required to schedule another office visit. Patients who miss two appointments in a row may be dismissed from the practice. Each missed appointment will increase the fee by $50 (1st $50 2nd $100 3rd $150 Three non-consecutive late cancellations or no-shows may result in dismissal from the practice. If you are a new patient, and do not call or show up for your first appointment, you may be dismissed from the practice. Discharge from the practice, no matter the reason, will result in at least a $150 fee in addition to the no show or late cancellation fees.

Returned Checks

All returned checks will be charged a $30 processing fee. Checks for amounts under $250.00 will be accepted. Any charges over $250 require payment with a credit card, debit card, or cash. Outstanding Balances: It is our office policy that all past due accounts be sent three statements. If payment is not made on your account after 60 days from the original statement, the credit card on file will be charged. If we are unable to receive payment using the credit card on file, the account will be sent to a collection agency and a

processing/discharge fee of $150 will be charged. We reserve the right to pursue all unpaid balances, which may include legal proceedings. We will ask that the parent/legal guardian bringing the child into the office pay the co-payment, deposit, and/or outstanding balance at the time of the visit. We will not bill or split bill the other parent at any time. Statements go to one parent, the one who brings the patient in for their appointment, and they are free to forward copies on to the other parent. If your divorce decree or custody documents state a split on who is responsible for medical expenses, this is an issue to take up with your attorney. We require that payment be made to us, and you or your attorney can seek reimbursement from the other parent. Failure to pay bills will result in dismissal from the practice.

Minors:

The parent(s) or guardian(s) is responsible for full payment and will receive the billing statements. All minors under the age of 18 years must be accompanied by a legal guardian. If an adult who is not alegal guardian will be bringing a minor to their appointment, we will need to have a consent form signed. This includes grandparents. This form may be obtained on our website www.akfamilyderm.com. The parent must be available for telephone consultation at the time of visit. The providers have the right to not treat the patient if the presence of the parent/legal guardian is deemed necessary for treatment.

Your signature indicates that you have read and understand the Alaska Family Dermatology LLC Financial and Office Policies and are legally authorized to do SO for the patient who has an appointment with Alaska Family Dermatology LLC.

Methods of Payment:

Our office accepts cash, check (under $250), debit cards, and all major credit cards.

I have had the chance to review the Alaska Family Dermatology Patient Financial & Office Policies as part of this registration process. I understand that the terms of these consents may change and I may obtain these revised notices by contacting the practice by phone or in writing.