Thank you for choosing to see Dr. Becca Joy Chibnall at Meramec Dermatology for your skin care needs. I am dedicated to providing the best possible care and services for you.
Knowing your financial responsibility is an essential element of your care. With healthcare costs shifting to patient responsibility, it is essential you understand your deductible and details of your plan.
Please read carefully and sign at the bottom to confirm your understanding.
1) Insurance: your visit is filed with your insurance carrier with whom our practice has a valid contract. It is the responsibility of the patient to provide accurate insurance and personal information including any preferred laboratory cards. If your insurance requires a referral, it is your responsibility to provide the referral prior to your visit.
Per your contract with your insurance company, a co-payment, co-insurance, or deductible may be due at the time of your visit. These are calculated based on our best efforts, and any differences will be billed or credited to you. You will be responsible at the time of service for the payment of such copays or deductibles, as well as any past due balances.
Recent changes in healthcare markets have altered insurance coverages to shift more of the cost of care to our patients. Many policies have higher deductibles which means, even if a procedure is covered by insurance, you may be responsible for the majority or entirety of the visit charges until your deductible is met.
2) Late cancellations and missed appointments: We understand that unexpected events, illnesses, etc. occur. When this happens, please call our office as soon possible to inform us of such issues. We do not double book these appointments, so the time period in which you are scheduled is reserved only for you. In the case of missed appointments or cancellations with less than 24 hours notice prior to the appointment:
a) Vulvovaginal dermatology appointments - I understand that it is my responsibility to cancel or change my appointment at least 24 hours prior to my appointment time and date, otherwise a $100 fee will be charged to my account which is not covered by my insurance plan. I understand that I will be unable to schedule another vulvovaginal clinic appointment until this fee has been paid.
b) Multiple no shows and/or late cancellations may result in discharge from the practice.
3) Cosmetic services: Cosmetic services cannot be billed to insurance, nor can we knowingly try to bill insurance in the hope that they may be covered. The fees associated with any cosmetic services are billed separately from any medically necessary evaluation or treatment. Charges for cosmeticservices must be paid in full at the time of service.
4) Pathology and laboratory fees: Biopsies are sent to an outside pathology lab. You will receive a separate bill from the pathology lab. Microbiology and other laboratory tests are performed by a separate lab that will bill you separately. Please contact the laboratory directly for questions regarding pathology or laboratory bills.
5) Requests for medical records: Printed copies of your medical records are available at a fee of 10 cents per page plus the cost of postage. Medical records may be sent to another medical provider at no charge.
6) Methods of payment: Meramec Dermatology accepts the following forms of payment: Cash, Visa, Mastercard and Discover and personal checks with proper identification (valid Driver’s license or photo ID). A $30.00 overdraft charge will be added to the insufficient funds amount of any returned checks.
Meramec Dermatology is committed to making our billing process as simple and easy as possible. We request that all patients with commercial insurance have a credit card on file with our office. The card information is stored in your patient medical record - the same HIPAA compliant software that protects your confidential medical information. After scanning, we can only view the last 4 digits and cannot access the complete card number.
Should you have a balance after your visit, we will mail out two statements. If no payment is received after 60 days, we will bill the card on file. By signing this form, you authorize Meramec Dermatology to bill your card on file.
I have read the above financial policies and understand my financial responsibilities as a patient. I understand that failure to make payment when due is the basis for legal action and agree to pay all costs of collection, including court costs and attorney fees. Any account not pending insurance that is 90 days past due will be turned over to a collections agency, and you will be discharged from the practice.