If you would like, you may authorize a trusted individual to receive healthcare information on your behalf. If you would like to do so, please fill in the following blanks below. I authorize Luna Dermatology to discuss my personal health information, including appointment details, treatment data, and lab results with the following individual: Person's Name , who is my Relationship . Their contact number is: Area Code Phone Number .
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.
General Terms 1) According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.
2) Co-payments are due at the time of service.
3) Self-pay patients are expected to pay for services in FULL at the time of the visit.
4) 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.
5) Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 10 business days of your receipt of your bill.
6) If previous arrangements have not been made with our office (in writing), any account balance outstanding longer than 90 days will be forwarded to a collection agency.
7) For scheduled appointments, prior balances must be paid in full prior to the visit.
8) If you participate with a high-deductible health plan, we require a copy of the health savings account debit or credit card, or a copy of a personal credit card to remain on file.
9) We accept cash, checks, and most credit and debit cards (including Visa, Mastercard, and American Express).
10) A $50 fee will be charged for any checks returned for insufficient funds.
1) 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.
2) 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 familarize yourself with what is covered before receiving treatment. If services rendered are not covered by your plan, you will be responsible for payment.
3) 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.
Missed Appointments and Late CancellationsKeeping an accurate and orderly schedule is imperative to running a successful practice and maintaining availability for fellow patients. You will be charged a fee of $25.00 for medical appointments and $50.00 for cosmetic appointments that you miss or fail to reschedule at least 24 hours prior to your scheduled visit. You agree that this amount will be automatically collected as a matter of policy and that the balance must be paid in full before your next appointment.
Non-Payment on AccountShould collection proceedings or other legal action become necessary to collect an overdue account and missed appointments/late cancellations, 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. The Patient, or the Patient’s Responsible Party, understands that they are responsible for all costs of collection including, but not limited to, interest due at a 18% per annum (or the highest rate permitted by law, if lesser), all court costs and attorneys’ fees, and collection fees, which will be added to the outstanding balance.
Non-participating Insurance Plans
For those who are insured by insurance carriers the practice does not participate with, you acknowledge that you (the patient) are responsible in full for any service charges at Luna Dermatology. Upon request, your insurance company may be billed as a non-assigned claim as a courtesy to the patient, but this does not relieve the patient from initially paying the practice the amount in full at the time of service. Once a non-assigned courtesy claim is sent to your insurance company, they will determine reimbursement to you accordingly. AUTHORIZATION FOR RELEASE OF INFORMATION AND PAYMENT
I authorize the release of any medical information requested by my insurance carrier (including HIV/AIDS, drug and alcohol abuse, and mental health) for administration of claims and services, and the release of information back to my physician. I also authorize payment of medical 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.
I request that payment of authorized MEDICARE benefits be made on my behalf to LUNA DERMATOLOGY for any services furnished to me by those physicians/providers. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agent to any information needed to determine these benefits or the benefits payable for related services.