Mitchell Dermatology Financial Policy

Proof of insurance - We must obtain a copy of your driver's license and current valid insurance card. If you fail to provide us with the correct insurance information in a timely manner or do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions regarding your coverage.

Claim Submission - We will submit your claims and assist you in any way we reasonably can to help you get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. The balance of your claim is your responsibility, whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. All co-payments, coinsurances, or deductibles are due at the time of service as we have the up-to-date fee schedules for each contracted insurance company.

Responsible party - We realize that many families are in a state of change. Divorced, Separated, single parents, and blended families are now common. In many of those families, the question of who is financially responsible for the child’s care can be complicated. The policy in this office is that the parent/ guardian, who is present with the minor requesting treatment, is responsible for payment at the time of service.

Statements - Any unanticipated balance must be paid upon receipt of your EOB or the first statement. Any balance outstanding for more than 60 days after the balance has been transferred to you will be sent to collections. Fees associated with the collection process will be added to your balance. If a balance remains unpaid, you and your immediate family members may also be discharged from the practice.

Forms of Payment - We accept cash, check, American Express, Discover. Master Card, Visa, Care Credit, and Money Orders. A $30.00 service fee will be accessed for each returned check to cover the corresponding bank charges. Payment of the returned check and service fee must be made in the form of cash, money order, or credit card.

By signing below, I acknowledge that I read and understand this financial policy.

**Supplying your credit card is optional** 

*You will not receive statements from our office if you choose this option*

I authorize Mitchell Dermatology to charge outstanding balances after the insurance has processed my claim on my account to the following credit card. I understand that I will not receive a statement unless my card is declined and that payment will be due immediately.