Private Pay (Self-Pay): I understand that if I do not have health insurance, full payment is due at the time of service.
Policy Benefits / Non-Covered Charges: I understand it is my responsibility to know my insurance policy coverage and benefits and to notify DSA Dermatology of any insurance changes in a timely manner. Many insurance companies have additional stipulations that may affect my coverage. I understand that I am responsible for any amounts not covered by my insurer. Routine in-office procedures, including but not limited to, biopsies, injections, destruction of precancerous and non-cancerous growths and surgical removal and repair of cancerous and non-cancerous growths and Mohs surgery are billed separately from my office visit and may be subject to my deductible or coinsurance. I agree to fulfill all policy provisions which my insurance companies may require for payment.
Copayments: I understand that all copays are due at the time of my appointment and before I see the provider. Given that DSA Dermatology physicians are specialists, a higher copay may be required.
Deductibles: I understand that if it is determined that my insurance policy has an unmet deductible, payment for services at the contracted rate between DSA Dermatology and my insurer will be due at the time of service.
Managed Care (HMO) Plans or Health Select: I understand it is my responsibility to obtain any and all necessary referrals including referrals for follow-up visits if my plan requires one. DSA Dermatology will strive to keep me informed of visits remaining on a referral and/or the expiration date but it is ultimately my responsibility to know this information and to make the necessary arrangements through my primary care physician. I understand that failure to obtain a referral if required by my insurance for coverage will result in me bearing complete financial responsibility for any and all services received.
Benefit Representation: I understand that the staff of DSA Dermatology will make every effort to accurately verify my insurance benefits but I will not solely rely on this preliminary verification as a basis for making financial decisions regarding treatment. I understand that I have a right to refuse any and all services before they are rendered if I think they are non-covered services or non-payable by my insurance. I understand that the final determination regarding my benefits and any amounts owed will be made by my insurer at the time of claim processing according to the provisions of the policy contract that I have with them.
Assignment of Benefits: I understand I must provide a copy of my current insurance card in order to file an insurance claim. I assign directly to the providers at DSA Dermatology all insurance benefits, if any, otherwise payable to me for services rendered. If a Medicare patient, I request that payment of authorized benefits be made on my behalf. I understand that I am financially responsible for all charges whether or not paid by insurance or Medicare. I further agree to pay for any items or services not covered by insurance or Medicare, as applicable. I hereby authorize the DSA Dermatology to release all information necessary to secure all payments or approvals of benefits.
Payment for Ancillary Services (Laboratory/Pathology): I understand that DSA Dermatology utilizes the services of outside laboratories for pathology (biopsies), microbiology (cultures), and blood chemistry. These laboratories will bill for services separately from DSA Dermatology. I acknowledge that payments made to DSA Dermatology are for services rendered by DSA Dermatology and authorize the use of outside laboratories as deemed necessary and warranted by my doctor(s). I understand that this may result in financial responsibility to the laboratory providing these diagnostic services.
Worker’s Compensation: I understand that DSA Dermatology does not accept Worker’ compensation cases.
Returned Checks: I understand that checks presented to DSA Dermatology as payment for services rendered and subsequently returned by my bank for any reason as unpaid will be charged a returned check fee of $25. Balances must be handled by cash, credit card, or money order. DSA Dermatology reserves the right to represent returned checks electronically for their face value plus the returned check fee.
Past Due Accounts: I understand that all outstanding accounts will be turned over to a collection agency after three statements and one pre-collection letter. I acknowledge that I must contact DSA Dermatology before this time if I wish to make other payment arrangements.