I understand that if I do not have insurance I will be self-pay, and $100 down payment will be required at the time of service. I understand that I will be balance billed any additional charges.
Clearview Dermatology bills all insurance companies as a courtesy to our patients. I understand it is ultimately the parent/guardian responsiblity to ensure all services are paid in full.
I authorize Clearview Dermatology, LLC (aka Leominster Dermatology, LLP) to release my medical diagnosis to my primary care physician, other health care facilitiy(s), or specialst(s) as necessary to coordinate my care.
I authorize any holder of medical or other inforation about me to release to the Social Security Administration/Health Care Financing Administration, its intermediaries/carriers, and/or any other health insurance carrier any information needed for this or related health insurance claim. I permit a copy of this authorization to be used in place of the original, and request payment of insurance benefits be made directly to the provider who accepts assignment.