NOTICE OF PRIVACY PRACTICES
We are required by law to provide you with a copy of our Notices of Privacy Practices. To ensure that our records are accurate, please sign this form and return it to our client services staff to acknowledge that you have been provided a copy of our notice.
Advanced Dermatology has contracts with many insurance plans. Please check with our client services to determine whether we participate with your specific insurance carrier. If we contract with your plan, we will file a claim (for non-cosmetic dermatology services) to your insurance company. You will be responsible for any co-pays, deductibles, purchased products, and/or non-covered service. If you do not have one of the plans with which the practice is contracted, the total cost of your visit is required at the time of your service.
• Should any blood work be done, a separate invoice will be sent to you from our contracted lab, which will be your responsibility to pay directly to them. This is in addition to our charges.
• Many plans, including HMO and POS plans, require referral authorization from your Primary Care Provider (PCP) in order for your visit with us to be covered. It is your responsibility to obtain this information.
• It is your responsibility to provide Advanced Dermatology with your current insurance information. Failure to do so may result in charges being billed directly to you.
• Any service that is not covered by your insurance company, for whatever reasons, is your financial responsibility. 30 days following insurance response any unpaid balances will be charged to the credit card on file. For patients requiring a payment plan a $2.00 processing fee will be applied to each payment.
• All cosmetic and laser services must be paid at the time of service or will be charged to the credit card on file.