I understand and agree that payment of authorized benefits under my insurance carrier(s) will be made to my provider for any covered services rendered at Braun Dermatology.

Braun Dermatology (BD) typically verifies insurance coverage as a courtesy, but you or your legal representative are ultimately responsible for understanding the details of your insurance plan regarding copays, co-insurance, or deductibles for any visits or procedures you schedule with us. You are fully financially responsible for any deductibles due the day of your appointment and balance resulting from your care at BD.

It is the patient’s responsibility to provide BD with accurate and updated contact information, mailing address, and insurance information. If no insurance information is provided, or the information is inaccurate, you will be considered a self-pay patient for the services provided that day.

Modernizing Medicine Inc. system will store your card information on a secure and encrypted site. Once your insurance has paid their portion, any remaining balance due will be charged to the card on file and a receipt will be emailed to you. A valid credit card, debit card, HSA or FSA card will be accepted. I (we), the undersigned, authorize and request that BD charge my card on file for the balance due that my health plan has identified as my financial responsibility. This authorization will remain in effect until revoked by me in writing.

Our office sends skin samples to independent dermatopathology labs after biopsies and surgeries. We also send other specimens such as bacterial cultures to independent labs. These labs will charge your insurance separately. We will always try to send specimens to a lab that has a contract with your insurance, however it is ultimately your responsibility to know which labs are preferred by your insurance company. Any charge from the lab will be the patient’s responsibility and any questions regarding that bill must be addressed by that patient with the lab or with their insurance company.

Some treatments are not covered by insurance. If BD knows with certainty that the treatment (such as removal of benign growths) is not covered, the patient will be informed of the cost and payment will be due at the time of service. If a treatment is billed to insurance, and the insurance declines to pay for that treatment, the patient will be responsible for payment and will be billed.

BD will mail and email a statement to patients who have any outstanding balances. Payments are due upon receipt of this statement, and can be paid online at braundermatology.com (“make a payment” link), a phone call to give our staff credit card information, or via check mailed to our office. Any outstanding balances older than 90 days may be sent to a collection agency, in which case the patient is responsible for their balance and the agency’s collection fee. Failure to pay outstanding balances may also result in discharge from our practice.

 Patients must provide ID and proof of insurance at each visit.

All patients are asked to arrive 15 minutes before their scheduled appointment, so the check-in process is complete before the appointment time. Any patient arriving late may be asked to reschedule, or may be seen as a work-in later in the day. Our providers strive to run on time, and we ask our patients’ cooperation towards that goal.

If you cannot make your scheduled medical appointment, you must cancel at least 24 hours (one business day) before the appointment time. Failure to do so will result in a $55.00 NO SHOW/LATE CANCELATION FEE. While BD tries to send courtesy appointment reminders via email/text/phone call, it is ultimately your responsibility to remember and keep the appointment. If you have been charged a no show/cancellation fee and believe that you have extenuating circumstances (sudden illness or accident) and would like to explain, please send a letter of appeal to either location (ATTN: Canceled Appointments) to include a doctor's note/police report or supporting documentation.

In a one year period, if a patient misses an appointment (or cancels with less than 24 hours notice) three times, the patient will be automatically discharged from the practice. For new patients, two missed/last minute cancellations will lead to discharge.

Full payment for all cosmetic procedures are due at the time of service. The company will not hold a deposit fee for cosmetic procedures and or encounters. When scheduling a cosmetic procedure and or consult, Braun Dermatology will hold a credit card on file in your account for any cosmetic appointments. If you fail to give 48 hour notice of cancellation for any cosmetic procedure, it will result in a $200.00 cosmetic “NO SHOW FEE” that will be charged to the credit card on file, regardless of circumstances. If a refund on a cosmetic procedure is requested more than 48 hours after booking, there is a $75 processing fee.

While your provider or BD staff member will typically communicate biopsy/lab results to you within 2 weeks, sometimes there are delays. If you have not been notified of biopsy results within 2 weeks, please call our office. If you have had bloodwork done outside our office, it is your responsibility to notify BD when and where you had the tests drawn, as Quest/LabCorp do not always send results automatically or in a timely manner.

I understand that BD may contact me using phone calls (live or automated), emails, or text messaging. These communications may serve as appointment reminders, or may be used to give test results, treatment recommendations, outstanding balances, or other information.

Braun Dermatology will NOT tolerate the mistreatment of staff and providers, to include yelling, belligerent, aggressive or threatening language. We will also not tolerate online bullying with reviews that are slanderous and untrue. For the mental health of our staff, any patients that mistreat our staff and providers will be discharged from the practice.

I authorize Braun Dermatology to release any medical or other information requested by my insurance company if necessary to process an insurance claim or determine medication coverage.

Patients may use the portal to obtain copies of their medical records. If the office is asked to provide those copies, there will be a fee (for patients, $10 for the first 20 pages then $0.10 for every additional page). If an outside source (such as an employer) requests records, the fee will be $55.

I acknowledge that I have fully read and understand the office policies listed above. I agree to the terms and conditions in this document. All questions and concerns regarding office policies have been addressed and answered to my satisfaction.

I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain patient rights regarding my protected health information.

I understand that Braun Dermatology & Skin Cancer Center P.C.. may use or disclose my protected health information for treatment, payment, or health care operations—which means for providing health care to me, the patient; handling billing and payment; and taking care of other health care operations. Unless required by law, there will be no other use or disclosure of this information without my authorization.

Braun Dermatology & Skin Cancer Center P.C. has a detailed document called the ‘Notice of Privacy Practices’. It contains a more complete description of my rights to privacy and how the office may use and disclose protected health information.

I understand that I have the right to read the ‘Notice’ before signing this agreement. If I ask, Braun Dermatology & Skin Cancer Center P.C. will provide me with the most current Notice of Privacy Practices.

My signature below indicates that I have been given the chance to review the Notice of Privacy Practices and that I agree to allow Braun Dermatology & Skin Cancer Center P.C. to use and disclose my protected health information to carry out treatment, payment, and health care operations. I have the right to revoke this consent in writing at any time, except to the extent that Braun Dermatology & Skin Cancer Center P.C. has taken action relying on this consent.