Office Policies and Assignment of Benefits
***YOU ARE RESPONSIBLE FOR YOUR INSURANCE POLICY***
Due to the many changes in insurance policies, we cannot be responsible for interpreting each individual policy. It is the responsibility of the patient to understand their individual coverage and its limitations, as well as the providers accepted by the plan. We urge you to check with your insurance company regarding your benefits because failure to comply could result in you, the patient, being responsible for all costs incurred.
Insurance Policies are a contract between the patient and the carrier. It is the responsibility of the patient
to know which providers are in their specific network.
Financial Responsibility: Patients are financially responsible for all charges, whether or not paid by their insurance, for all services rendered on their behalf or dependent’s behalf.
Payment: Any and all co-pays, co-insurance, deductibles and account balances are due at the time of service.
Balances: Balances outstanding for more than 90 days will be subject to collection fees (at the patient’s expense) and may be referred to a collection agency.
Referral/Authorizations: If the patient’s health insurance policy requires a referral/authorization, it is the patient’s responsibility to obtain it prior to the scheduled appointment. Since most insurances will deny wellness visits for Dermatologists we do not offer this service.
Return Policy: Any defective product or any product that has caused an allergic reaction which has been documented by a physician, may be returned within 30 days. Prescription strength products are non returnable.
Appointment Cancellation Policy: A fee of $50 will be charged for any/all medical appointments and $100 for any surgical appointment not cancelled within 24 hours. Cosmetic appointments will require a deposit of$50-$200 depending on type ofthe appointment, and this deposit amount will be charged as a fee, ifthe appointment is cancelled with less than 24 hours notice. These fees may be waived at the discretion of the billing office, one time only, if there is an emergency (hospitalization, accident, etc …).
Lab Fees: Please be advised that all specimens (biopsy, cultures, etc.) will be sent to an independent Lab to be processed and you will receive a separate bill from that Lab.
Returned Check Policy: A fee of $50 will be charged for each check that is returned and is subject to change.
I certify that all of the insurance information that I have provided is current and correct. I authorize Siperstein Dermatology to administer medical care as deemed necessary. I authorize the release of any medical information requested by my insurance carrier in order to process insurance claims. I understand that I am personally responsible for all fees, including deductibles, copays, and co-insurance incurred for services rendered to me or a dependent. I authorize payment of insurance benefits paid on my behalf to be made directly to Siperstein Dermatology.
