At McLean & Potomac Dermatology and Skincare Center, we are committed to providing the best dermatologic care.
This agreement must be signed in order to be seen by providers at McLean & Potomac Dermatology and Skincare Center
OFFICE FEES AND PAYMENTS
A. There are fees for all services performed by our providers and staff, including consultations and procedures.
B. As the patient or guarantor, you are responsible for all charges for your visits, including co-‐payments AT TIME OF SERVICE, deductibles, and coinsurance amounts that are due per your insurance plan.
C. OUR OFFICE POLICY REQUIRES A CREDIT CARD TO BE PUT ON FILE AND WILL ONLY BE CHARGED FOR ANY OUTSTANDING BALANCES, AFTER INSURANCE PAYMENTS HAVE PROCESSED – BY THE BILLING DEPARTMENT.
D. Cosmetic services cannot be processed through insurance, and fees for such services are due at the time of service. All sales are final.
E. General dermatology services will be processed through the insurance on file or payment is due at time of service by the patient – if no insurance is on file.
F. If there is a balance due after insurance pays for your visit, the difference owed is patient responsibility.
G. Charges for all visits and procedures that are not processed by insurance are due at the time of service.
H. Medicare patients are responsible for any balances due for services that are not covered by Medicare.
I. If you have an outstanding balance on your account, it must be paid in full before your next visit.
J. We accept cash and all major credit cards. We do not accept checks.
K. For any NSF check (checks returned for non-‐sufficient funds), a $50 NSF charge will be billed to your account.
L. If proof of insurance is not provided at the time of service, you are responsible for the entire fee for the consultation and/or procedure at the time of service.
In the case of an account overpayment, a credit will remain on your account unless you request a refund.
A. Your insurance policy is a contract between you and your insurance company. It is essential that you understand which services and procedures are covered by your insurance plan and obtain any necessary authorizations or referrals prior to your appointment with us.
B. We accept plans through the following payers as in-network providers: Aetna, Anthem BCBS, Federal BCBS, Carefirst Blue Choice, Cigna, United Healthcare, GEHA, UMR, Medicare.
C. We cannot guarantee that we accept your specific plan as an in-network provider; it is your responsibility to verify your insurance benefits and coverage prior to your visits.
D. We will not submit claims to any other insurance company other than those listed above. If you have a secondary insurance in addition to one of the plans listed above, we will file a claim to your secondary insurance as an out-of-network provider. In such instances, we cannot guarantee complete coverage.
E. If we do not accept your insurance, the charges for all services are due in full at the time of service. All sales are final.
F. Please note: several United Student Resources plans do not cover hair loss visits; verify your coverage and benefits prior to your visit so you are aware of your plan benefits and limits.
G. It is your responsibility as the patient to understand your insurance plan limits and restrictions that affect coverage of services you receive.
H. If you have biopsy or any lab testing in our office, you and/or your insurance will be billed for the corresponding lab charges. The lab is a third party and will bill you for remaining balances. THE THIRD PARTY LAB FOR PATHOLOGY IS FAIRVIEW LAB IN MINNESOTA. OUR OTHER THIRD PARTY FACILITY FOR ALL OF OUR LAB TESTING IS LabCorp.
I. If your insurance company requires you to use a specific laboratory in order for laboratory fees to be covered, it is your
responsibility to request this.
48-HOUR CANCELLATION POLICY
A. You will be billed a $50 “No Show/Cancellation Fee” for each appointment cancelled or missed without 48-hour notice.
B. You will be billed a $150 “No Show Fee/Cancellation” for all procedure appointments cancelled or missed without 48-hour notice (Excisions, surgeries, etc.)
In the event that your account is put into collections, the balance must be paid in full – in order to schedule any future office appointments or even request prescription refills.
A. By signing below, you authorize the release of any medical or other information necessary to process claims related to general dermatology (medical) services received by yourself or your dependent. You assign all medical payment on your behalf or that of your dependent for services provided to be issued to McLean Dermatology and Skincare Center, PLLC, 6849 Old Dominion Dr., Suite 450, McLean, VA 22101; or issued to Potomac Dermatology and Skincare Center, PLLC, 9812 Falls Road, Suite 124, Potomac, MD 20854.
We are required by law to provide you with a copy of our Notice of Privacy Practices and our Financial Agreement.
By signing this agreement, you acknowledge that you have received and read our Notice of Privacy Practices and fully understand and accept the terms of the McLean & Potomac Dermatology and Skincare Center Notice of Privacy Practices and Financial Agreement.