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.
- According to your insurance plan, you are responsible for all co-payments, deductibles, and coinsurances.
- We accept cash, checks, credit / debit cards, and CareCredit financing. 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.
- Patient balances are billed 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, or you are a self-pay patient, 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.
Insurance Plans:
- It is your responsibility to keep us updated with your correct insurance information. If the insurance you designate is incorrect, you will be responsible for payment of the visit and submission to the correct plan for reimbursement.
- It is your responsibility to understand your benefit plan regarding in-network providers, covered services, and participating laboratories. Every insurance By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical 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 and valid as the original.
Laboratory/Pathology Charges:
- Depending on your insurance carrier, 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, and we encourage all patients to familiarize themselves with their coverage as we do not have control over that process.
Cosmetic Services:
- We provide both medical and cosmetic dermatologic services. 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 reschedule or pay for the visit at the time of service.
Missed Appointments and Late Cancellations:
- When patients fail to show for their appointment, or cancel last minute, it disrupts the schedule and creates a burden on other patients. 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 may be subject to collection proceedings. 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 / Product Return Policy:
- We offer returns on most unused products within 30 days of purchase. 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. This information is encrypted and stored securely. The card on file will be charged 30 days after a billing statement has been sent to your address.
- I authorize Luna Dermatology to charge the credit card on file automatically for payments owed to my account (or for the patient noted at the bottom of this form) for services rendered. I agree to update any information regarding this account to keep it current. I authorize Luna Dermatology to charge my card in full for any outstanding balances.
By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical 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 and valid as the original.