Dear Patient:

We appreciate your confidence in choosing Accent Dermatology and Laser Institute, PLLC for your skin care needs. Please take a moment to review our financial policy so that you understand your responsibility regarding the charges for the services rendered to you by this office. We require you to read and sign our electronic version of this document prior to receiving treatment.

When asked, and as a courtesy to you, we will try to give you general guidelines about what your insurance policy might cover. Since medical insurance is an agreement entered into by you and your insurance carrier, you are ultimately responsible for knowing the specifics of what your policy covers and for notifying us when your insurance changes. Failure to update us with changes in your insurance coverage may result in a denial of coverage from your carrier, and in that case, you would be responsible for payment of the entire amount due. Payment is due at the time of service. Acceptable forms of payment are cash, check, VISA, MasterCard and Discover.

IF YOU ARE A SELF PAYING PATIENT – AT CHECK-IN WE WILL ASK YOU TO ALLOW US TO TAKE A COPY OF YOUR DRIVER’S LICENSE AND A BLANK CHECK OR COPY OF YOUR CREDIT CARD PRIOR TO YOUR VISIT WITH THE PHYSICIAN. THIS WILL BE USED AT CHECK-OUT.

If we participate (i.e. are contracted) with a commercial insurance plan under which you are covered, we will bill the carrier for the charges that relate to COVERED services rendered. This means that services for the removal of benign lesions, which are not likely covered by insurances (for example: skin tags, seborrheic keratosis, telangiectasiae, leg veins, and other COSMETIC procedures), will be paid at the time of service. We will bill both your primary and secondary insurance plans for covered services under the contracted plans. Complete insurance information, including referrals from other providers, for primary and secondary insurance coverage(s) must be made available to the Practice including all identification, benefits cards/documents, and any other information required by your insurance carrier, for accurate filing of claims. In the event that we are not aware of a charge that is not covered by your plan, you will be billed the balance after we obtain the denial from your insurance. You are responsible AT THE TIME OF SERVICE for payment of: co-payments, and/or charges for non-covered or cosmetic services.

ABOUT CO-PAYMENTS: If you are an enrollee of a managed care plan (HMO or PPO) that we are contracted with, you are required to pay the co-payment each time you are seen, (including follow-up appointments) and it must be paid before you see the physician. If you are not prepared to pay the co-payment, the visit must be rescheduled. If you do not know your co-payment, we will collect $25.00 for your co-payment at check-in.

ABOUT REFERRALS: If you are enrolled in an HMO or other plan which requires a referral from your primary care physician, you must have the referral with you OR the referral must have been sent to us in advance of your visit in order to be seen by the physician. You are responsible for obtaining your own referral (from your primary care physician), FOR EVERY VISIT.

Medicare Patients: We are Medicare participating providers. We will bill Medicare and the Medigap carriers. You will be responsible at the time of service for co-payments and charges for non-covered or cosmetic services.

*YOU WILL BE ASKED TO SIGN A WAIVER OF LIABILITY FORM KNOWN AS AN ABN (ADVANCED BENEFICIARY NOTICE) IN THE EVENT THAT A SERVICE IS PROVIDED WHICH WE KNOW IS NOT, OR HAVE REASON TO BELIEVE MAY NOT BE COVERED BY MEDICARE.

If you have Medicare as well as secondary coverage with a commercial plan that is not Medigap or is an insurance company with which we have no contract, we will file a claim to your secondary/supplemental carrier. If no payment is received from your secondary/supplemental carrier within 60 days after we file a claim, you will be sent a bill, and you will be responsible for the balance.

For non-Medicare patients: If you have insurance coverage with an insurance carrier with which we have no contractual relationship, please note the following: you are responsible, at the time of service, for payment of all services. You will receive forms at the time of service which you can use to bill your primary and secondary insurance plans for any reimbursement that may be due from you under your policy. Please understand that since we do not have a contract with your plan, we are not obligated to adjust our charges based on your plan’s coverage or benefits.

Cancellation Policy: We recognize that everyone’s time is valuable, so we make every effort to maintain the scheduled appointment times. If you arrive more than 10 minutes late for your scheduled appointment you may be asked to reschedule.

THIS TIME IS RESERVED EXCLUSIVELY FOR YOU. WE REQUEST THAT YOU ALLOW ONE HOUR TO BE IN OUR OFFICE. BEGINNING JANUARY 2017, WE WILL CHARGE $35.00 FOR EVERY MISSED MEDICAL APPOINTMENT / APPOINTMENT CANCELED WITHOUT 24 HOURS’ ADVANCE NOTICE. AFTER ANY COMBINATION OF 3 MISSED APPOINTMENTS / APPOINTMENTS CANCELED WITHOUT 24 HOURS’ ADVANCE NOTICE, YOU WILL BE DISCHARGED FROM THE PRACTICE UNLESS THERE ARE EXTENUATING CIRCUMSTANCES.

Cosmetic Cancellation Policy: Should you need to cancel or change the date of your procedure, we require at least 24 HOURS NOTICE as a courtesy to other patients seeking our services. Any procedure canceled without 24 hours notice will incur a $100.00 CANCELLATION FEE. A credit card number may be required to hold your reservation.

Rx Refills: Please contact your pharmacy for any refill requests; they will electronically contact the office for approval. Allow up to 48 business hours for refills to be completed. Refills received after 3:00 PM on Friday will be considered part of Monday’s business.

Surescripts: By signing this form, you are giving Accent Dermatology permission to access your insurance prescription formulary through surescripts. This lets us see what medications are on your insurance company’s formulary, and it helps us determine which medications are covered by your insurance policy.

Divorce Situations: We look to the adult who has brought the child in for the appointment to be responsible for payment of the services which are rendered to the child. We expect the parents to be able to work out payment arrangements with one another. Our office staff will not participate in any disputes which may arise with respect to financial liability or responsibility.