INSURANCE: Patients must present with the proper insurance documents at the time of service in order for KIRSCH DERMATOLOGY to properly file claims in a timely fashion. If the necessary information is not received in a timely fashion, KIRSCH DERMATOLOGY will not be responsible for denials and/or patient balances as a result. Patients are responsible for maintaining active coverage, obtaining proper referrals, confirming their provider’s participation in the network and their own familiarity with the benefit package therein. KIRSCH DERMATOLOGY reserves the right to collect copays and estimated patient liability at the time of service in line with the current insurance carrier contracts.
AUTHORIZATIONS: The patient understands that all surgical cases are authorized by the KIRSCH DERMATOLOGY prior to the scheduled surgical date. The authorization process can take up to 45 business days per insurance contracts and guidelines. The patient understands that if approval is not obtained three (3) weeks prior to the surgical date, the patient must elect to reschedule or move forward as a self-pay/cosmetic patient.
OUTSIDE CHARGES: The patient understands that there may be additional outside charges for covered services such as laboratory, pathology, facility and anesthesia when applicable. The patient understands that KIRSCH DERMATOLOGY is available as a resource when problems arrive, but balances related to outside services must be addressed directly with the billing entity
ASSIGNMENT OF BENEFITS AND FINANCIAL RESPONSIBILTY: The patient hereby assigns all medical and/or surgical benefits from Medicare, private insurance and any other health plans to: The KIRSCH DERMATOLOGY. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.
The patient hereby authorizes said assignee to release all information necessary to secure the payment. The patient authorizes KIRSCH DERMATOLOGY to release any information acquired in the course of my exam or treatment to their insurance company, primary care physician, pediatrician or another physician. The patient recognizes that they are responsible for all charges incurred whether or not paid by their insurance company. They also recognize and agree that they will pay any amount not paid by their insurance company within 30 days. In the event the patient fails to comply with this financial policy, they understand that their account may be turned over to a collection agency. The patient understands and agrees that, they are ultimately responsible for the balance on the account for any professional services rendered. The patient agrees to notify the KIRSCH DERMATOLOGY of any changes in their health status or health insurance. If the patient is a member of an HMO or PPO group and the insurance company has not paid the claim within 90 days of the visit, the patient understands they are responsible for the balance due.
FINANCIAL HARDSHIP: KIRSCH DERMATOLOGY recognizes that patients may experience financial hardship from time to time, which prohibits them from paying their bills in a timely fashion. At its discretion, Kirsch Dermatology may offer reductions for patients that present for medically necessary procedures without insurance. Requests will be reviewed individually after being submitted in writing.
CREDIT CARD ON FILE: It is the policy of the KIRSCH DERMATOLOGY to keep a credit card on file for patient balances. All outstanding balances for patients after insurance processing or for self-pay charges not collected at the time of service (for any reason), will be charged at the beginning of the following calendar month. By agreeing to this policy, you are acknowledging and agreeing to have your card on file charged for any outstanding balances on a rolling monthly period. Our patients are acknowledge that they will receive three statements to the mailing address on file, then we may charge the credit card we have on file.
RETURNED CHECK POLICY: A $50.00 service charge will be levied on all checks returned due to insufficient funds or for any other reason. This will be added to the original check amount.
COVERED SERVICES: All cosmetic services are not covered by insurance and must be paid in full. If a patient decides to move forward cosmetically, they do so with the understanding that KIRSCH DERMATOLOGY will not accept assignment of benefits, nor will the KIRSCH DERMATOLOGY submit for coverage thereafter or assist in the patient submission process.
COSMETIC NO SHOW FEES: Cosmetic consultations carry a $100.00 non-refundable charge at the time of booking. This fee is applicable towards the total cost of the patient’s surgical treatment should they chose to schedule. In the event that a patient does not cancel their appointment with notice and “no-shows,” the deposit fee will be kept as a penalty.
SURGICAL DEPOSIT/PRE-PAYMENT: Patients that wish to book and hold a surgical date are required to pay a non-refundable deposit of $500.00, which is applicable towards the total cost of the surgery. This deposit is not transferrable to any other date of service if surgery is rescheduled. Payment in full must be received at least two (2) weeks prior to the scheduled surgical date. Your surgical date and deposit will be forfeited at that time in the event payment is not received.
REFUND POLICY: KIRSCH DERMATOLOGY makes every attempt to accommodate patients that need to reschedule. However, late cancellation often results in lost surgical scheduling time for KIRSCH DERMATOLOGY and as such do carry a fee as follows (does not include deposit):
- Cancellation within two (2) weeks of surgical date: 30% of total surgical fees forfeited.
- Cancellation within forty eight (48) hours: 50% of total surgical fees forfeited.
***As much as we dislike asking patients to sign credit card forms and cancellation policy forms, it is an unfortunate necessity in this age of high deductible plans and missed appointments.***