By accepting an appointment at Affinity Dermatology, you are agreeing to the terms of this Financial Policy (or on behalf of the patient if the patient is not the responsible party)
PAYMENT AT TIME OF SERVICE: Payment is due in full at the time of service unless you are covered by Medicare or an insurance company with which we participate.
INSURANCE: Patients will be asked to present their insurance card and drivers license to the receptionist for scanning to your chart upon check-in at the office each time they are seen for medical services. Please make it a point to bring your insurance card with you each time that you visit our office. Claims not paid within 45 days by your insurance company will become your responsibility. You will receive a statement for these services and you will need to contact your insurance company for reimbursement.
As a courtesy, we attempt to verify benefits prior to the visit. However, it is ultimately the PATIENT’S responsibility to verify that this office and their provider are contracted as participating providers with their plan prior to the visit. For those patients covered by insurance plans with which we ARE participating providers, payments for all co-payments, deductibles, co-insurance amounts, and non-covered services are due at the time of service. We will file your insurance claim to the insurance company. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service at the current self-pay rate. Your insurance policy is a contract between YOU and your insurance company. We cannot guarantee payment of your claims by your insurance company. Any charges that are not paid by your insurance company are your responsibility. Reduction or rejection of your claim by your insurance company does not relieve the financial obligation you have incurred.
Any pre-certifications for procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this. It is also your responsibility to understand your plan and request any desired cost estimates prior to treatment. Your consent to treatment is also constitutes consent that you will pay the contracted cost for the treatment or procedure.
REFERRAL AUTHORIZATION/HMO Plans: patients are responsible for obtaining a proper referral from their primary care physician (PCP) prior to the visit. If authorization is not obtained, you will be considered “self-pay” and will be responsible for the cost of the visit and any procedures at the time of the visit.
MEDICARE: We accept assignment and will file insurance for our Medicare patients. However, any calendar-year deductible amounts, up to the amount of the visit, are due at the time of service. We will also file with any secondary insurance after payment from Medicare is received if we are contracted with your secondary plan. If there is no secondary insurance, the patient will be billed for the remaining amount.
MEDICAID: We are NOT contracted with Medicaid and we are unable to accept patients who use Medicaid/CHIP as a primary form of insurance, nor are we able to accept patients who use Medicaid as a secondary plan to any other insurance product. We are also unable to accept patients who have Medicaid in any form as a cash-pay patient. This is due to contractual requirements placed upon participants and providers by the Center for Medicare and Medicaid Services.
INDEMNITY PATIENTS: We do not file insurance for our indemnity patients. Payment in full is expected at the time of the visit and a receipt will be provided for you to file with your insurance carrier.
RETURNED CHECKS: There will be a one hundred dollar ($100) fee assess for any returned check. This fee is assessed regardless of whether the check is deposited because the bank will have already charged us a fee for the returned item. You will subsequently receive a bill for this amount.
CREDIT BALANCES: If you account has a credit balance of more than $100, a refund will be mailed to you within 30 days.
COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency. You also agree that once our account is submitted to collections, this also terminates your relationship with Affinity Dermatology for future services beginning on the date of receipt of the collections notice, with the exception of emergency care during the period of 30 days beyond receipt of collections notice. All appointments scheduled prior to and after the receipt of the collections notice will be cancelled without notice. Should the patient desire to resume care with Affinity Dermatology, the outstanding balance must already be paid, and a $125 reinstatement fee will be due at the time of scheduling another appointment. Additionally, all current and future appointments will require prepayment at the time of scheduling.
POLICY UPDATES: This policy may be updated or changed at any time without prior notice.
AUTHORIZATION AND RELEASE: I authorize the release of my medical records to determine liability for payments, treatment, or to obtain reimbursement. I assign all medical benefits for office visits to Affinity Dermatology, PLLC. This assignment will remain in effect unless and until revoked by me in writing. A photocopy or electronically signed copy of this paperwork will have the same validity as the original.