FINANCIAL RESPONSIBILITY
I understand that although Coastal Skin Surgery and Dermatology will file a claim to my insurance plan(s), I am expected to pay my copayment, coinsurance, deductible and non-covered services amounts at the time services are rendered. I acknowledge that Coastal Skin Surgery and Dermatology does not guarantee payment of my claim by my insurance plan and that it is my responsibility to know the provisions of my insurance. Not all procedures are deemed “Medical Necessity” by insurance carriers and can be considered cosmetic. For example-Skin tag removal, correction of dark spots, yearly skin cancer screenings without specific areas of concern, would not be a covered service. I understand that I would be responsible for payment of such services. I am ultimately responsible for any unpaid balance or non-covered service. I agree to pay all costs of collecting, securing or attempting to collect or secure payment, including reasonable attorney fees or collection agency fees.
I also understand that any prior unpaid balances on my account must be paid in full before being seen by a provider. If my prior balance cannot be paid in full, I will speak with a financial counselor at Coastal Skin Surgery and Dermatology to make a payment arrangement before services can be rendered.
I also understand that if Coastal Skin Surgery and Dermatology does not participate with my insurance plan that I will be expected to pay in full for my services. And it is my responsibility to know if Coastal Skin Surgery and Dermatology is in network with my insurance plan. I understand that payments to Coastal Skin Surgery and Dermatology can be made by cash, checks and all major credit cards. I also acknowledge that returned checks will be subject to a non-sufficient fund fee of $25.00.