Office Financial Policy Acknowledgement

PAYMENT AT TIME OF SERVICE: Payments for MEDICAL services are due in full at the time of service unless you are covered by Medicare or an insurance plan with which we are a participating provider. Payments for SELF PAY and COSMETIC services and products are due in full at the time of service. A $25 service fee will be charged for any returned checks, without exception.

• Patients may be asked to present their insurance card to the receptionist for copying upon check-in at the office each time they are seen for medical services. It is essential that you bring your most up-to-date insurance card to ensure accurate billing.
  
  
• If we are a participating provider with your insurance plan, co-pays and payments for any non-covered services are due at the time of service. We will file the claim on your behalf, but you will be responsible for any remaining balance not covered by your insurance.
  
  
• It is your responsibility to confirm whether our office and providers are in-network with your insurance plan. We encourage you to contact your insurance company directly to verify our participation status before your visit.
  
  
• It is your responsibility to understand your insurance benefits, including any co-pays, deductibles, and non-covered services. We recommend that you check with your insurance provider to fully understand your plan’s coverage and any out-of-pocket costs you may incur.
  
  
• It is your responsibility to notify our office if your insurance coverage changes. Failure to inform us of a change may result in you being responsible for charges that are not covered under your new plan.
  
  
• If your insurance plan changes to one with which we are not a participating provider, full payment will be required at the time of service. It will be your responsibility to file the claim with your insurance company and seek reimbursement for any unpaid balance.
  
  
• Claims not paid within 45 days by your insurance company will become your responsibility. You will receive a statement for these charges, and it will be your responsibility to contact your insurance company for reimbursement.

MEDICARE: We are a participating provider with Medicare. Our office will file claims to Medicare and your secondary insurance on your behalf. You are responsible for the Medicare yearly deductible and 20% of the Medicare-approved coverage. You are responsible for any balance not paid by Medicare and your secondary insurance.

MEDICAID: We are not a Medicaid provider.

REFERRALS/PRE-CERTIFICATIONS: If your insurance plan requires a referral for specialist services, it is your responsibility to ensure that the referral is obtained and provided to our office prior to your appointment. Failure to provide a referral may result in services being billed to you directly. Any required pre-certifications for procedures or testing are your responsibility. Please notify us in advance if your insurance requires pre-certification, as we may need additional information to proceed.

THIRD-PARTY LAB TESTING: If any samples or tests (such as blood work, biopsies, or other diagnostic tests) are sent to third-party laboratories, the charges for those services are the patient's responsibility. You will receive a separate bill directly from the third-party lab, and payment for those services will be due to them, not our office. Please contact the lab directly for any questions regarding those charges.

PAYMENT: Statements are released after your insurance pays, denies, or non-payment occurs by your insurance. Full payment is due within 30 days of statement issue date. Your account will be subject to our collections process if it is not paid in full within 30 days. Please be aware that if you have a past-due balance on your account, you will not be able to schedule further appointments until the balance is paid in full.

By signing this document, I am agreeing to the terms of the above Office Financial Policy.