- Please note: Unpaid account balances will be assessed a $10.00 re-billing fee for each statement generated after 90 days passed. Late fees will begin accruing after 90 days.
- If your account is overdue for more than 120 days after your insurance has paid, it will be referred to a collection agency. This is done reluctantly, as a last resort, after we have exhausted all efforts for voluntary payment.
- New Patients, and those who have no insurance, are required to pay at the time of service with either a credit card or cash. We do not accept personal checks.
Acknowledgement and Authorization
I have read, understood and agree to abide by the above payment policy. I understand that charges not covered by my insurance company, as well as copayment, deductibles and coinsurances, are my responsibility.
One-Time Authorization for Recipients:
Irequest that my payment of authorized Medicare benefits be made to me on my behalf to Michael T. Lin MD., Inc for any services furnished to me. I authorize holders of medical information about me to release to the Centers for Medicare & Medicaid Services and it's agents any information needed to determine these benefits or the benefits payable for related services. Additionally, I request that payment of authorized Medi-gap benefits be made to either me or on my behalf to Michael T. Lin MD., Inc. for any services furnished by this provider. I authorize any benefits or the benefits payable for related services.
By signing below, you agree to the Terms and Conditions of Advanced Dermatology and Skin Cancer Institutes Payment Policies: