In order to establish optimal relations with our patients and avoid misunderstanding regarding our payment policies, our staff is trained to inform you of the financial policies of this office. Payment is expected from you, at the time of service, for "your part" of the charges. The policy of this office is that the parent who accompanies the patient is responsible for all fees for service rendered (only that parent will be billed). We accept visa, master-card, and discover for you convenience. Your signature below indicates that you understand and accept the policy. Further, your signature authorizes the physician to release such medical information necessary to process your insurance claim (if any). You herein authorize payment of medical benefits to the physician when assigned claim is filed. A patient may be charged a service fee for any missed appointments of repeats cancellations within twenty-four hours of the appointment time. The fee charged will be determined by the time allotted for the appointment. In the event that your account must be turned over to collections, you will be responsible for any additional fees added to your account. If your check is returned to us unpaid, $35 will be assessed to your account. Additionally, I acknowledge that I have received a copy of Jason B. Amato, M.D. Dermatology, LLC's Notice of privacy practices: