Payment:
- Payment for services, including co-payments, are due in full at the time of service. Prior balances must be paid in full prior to being seen at your next appointment.
- Per your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.
- We accept cash, checks, and credit/debit cards. Please note that we are only able to accept check payment for amounts up to $500. A $50 fee will be charged for any returned checks.
- Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 15 business days of your receipt of your bill. Prior balances must be paid in full before scheduling any appointments.
- If we do not participate in your insurance plan, payment in full is expected from you at the time of your visit. We will supply you with an invoice that you can submit to your insurance for reimbursement. Self-pay patients are expected to pay for services in full at the time of the visit.
Insurance Plans:
- It is your responsibility to keep us updated with your correct insurance information. If the insurance company you designate is incorrect, you will be responsible for payment of the visit and to submit the charges to the correct plan for reimbursement.
- It is your responsibility to understand your benefit plan with regard to in-network providers, covered services, and participating laboratories. Every insurance plan is different, so we encourage you to familiarize yourself with what is covered before receiving treatment. If you have questions on network status/participation with your insurance, it is your responsibility to contact your insurance company directly. If services rendered are not covered by your plan, you will be responsible for payment.
Laboratory/Pathology Charges:
- Depending on your insurance carrier’s policy, you may be required to pay a separate co-payment for any specimen taken during your visit. For example, biopsies need to be sent to a third-party laboratory for pathology reading and diagnostic testing. The charges for lab testing may be your responsibility or may be covered by insurance, depending on your respective plan, and we encourage all patients to familiarize themselves with their coverage as we do not have control over that part of the process.
Cosmetic Services:
- We provide both medical and cosmetic dermatologic services in our office. Please note that these services are billed separately, even if you are seen for both medical and cosmetic reasons during the same appointment.
- The removal of most benign growths is considered cosmetic and is not covered by insurance. The office visit consultation to determine if a growth is benign is billed to insurance.
Referrals:
- It is your responsibility to know if a written referral or authorization is required to see specialists, whether preauthorization is required prior to a procedure, and what services are covered. If your insurance has designated a primary care physician (PCP), you are required to have prior authorization from your PCP prior to your office visit with us. If authorization is not provided, you will be asked to either reschedule your appointment or pay for the visit at the time of service.
HSA/FSA/Flex Spend Programs:
- We are happy to accept HSA/FSA/Flex Spend Programs for all medical related expenses. Please note that we cannot accept HSA/FSA/Flex Spend Programs for any cosmetic or non-medically necessary services. If you have questions regarding whether your services are covered, please see the Front Desk.
Missed Appointments and Late Cancellations:
- We aim to provide you with convenient appointment times and accurate scheduling. When patients fail to show for their appointment, or cancel last minute, it disrupts the schedule and creates a burden on other patients and our team alike. As such, the following fees will apply if you do not show up for your appointment or fail to notify us of a need to change/cancel your appointment with at least 24-hours advanced notice.
- General Medical Visit: $50
- Cosmetic Consultation: $50
- Cosmetic Appointment: $100
- Surgical Appointment: $100
- Missed appointment / late cancellation fees will be charged via the credit card on file and we will email a receipt. No future appointments can be scheduled until the fees are paid.
Non-Payment on Account:
- Past due accounts are subject to collection proceedings. After 30 days past due we will attempt to run the card on file. If we are unable to run the card on file then we will send an additional statement. After 90 days your account will be turned over to our collection agency and you will be responsible for all collection and fees that the practice incurs as a result. The Patient or the Patient’s Responsible Party understands that Practice has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. We reserve the right to refuse to see any patient that has been placed into collections.
Aesthetic Packages/Return Policy:
- Products that are not well-tolerated by the patient or have defective packaging can be returned to the office within 30 days of purchase for a refund or exchange. Due to state laws, prescription products are not refundable.
Unless otherwise agreed to in writing, all packages for aesthetic services such as microneedling, PRP, and others, expire six months after purchase
Authorization for Release of Information and Payment:
- I authorize the release of any medical information requested by my insurance carrier for administration of claims and services, and the release of information back to my physician. I also authorize payment of medical benefits, including Medicare benefits, to BB Medical and Dermatology Inc (DBA Luna Dermatology) for services rendered. If my medical insurance does not pay for services rendered, I agree to pay Luna Dermatology for these services. If the patient is a minor, I acknowledge that the parent or legal guardian is responsible for payment of services.
Credit Card Preauthorization:
- In support of our efforts to promote seamless checkout, contactless billing, and our overall green initiative to reduce mailing materials, Luna Dermatology requires all patients to have a credit card on file. In addition, this is the best way to keep your account current. This information is encrypted and stored securely online. The card on file will be charged 30 days after one billing statement has been sent to your billing address. You will receive a receipt and explanation of any amounts processed and our team can always provide additional details upon request.
- I authorize Luna Dermatology to charge the credit card on file automatically for payments owed to my account (or for the patient otherwise noted at the bottom of this form) for services rendered at their office. I agree to update any information regarding this account to keep it current. I understand that this information is encrypted and stored securely online. I authorize Luna Dermatology to charge my card in full for any outstanding balances. Charges will only be made after the claim has been processed by the insurance carrier.
By signing below, you agree to accept full financial responsibility as a Patient who is receiving services, or as the Responsible Party. Your signature verifies that you have read this Patient Financial Responsibility statement, understand your responsibilities, and agree to these terms. A digital copy of this document shall be as effective as any original.