Patient Financial & Cancellation Policy

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.

FINANCIAL POLICY

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.

CANCELLATION POLICY

• MEDICAL PATIENTS: Please be advised that we require at least 24 hr notice to cancel or reschedule a medical appointment. A $50 fee will be assessed to your account with a cancelation or reschedule of less than 24 hours notice and will be charged to the credit card on file.
• COSMETIC PATIENTS: Please be advised that we require at least 72 hr notice to cancel or reschedule a cosmetic appointment. Should you cancel or reschedule less than 72 hours; a non-refundable fee of $100 per 30 minutes of appointment time will be assessed to your account and will be charged to the credit card on file.
• LATE ARRIVAL: All patients who are more than 15 minutes late for their appointment will not be seen and will be rescheduled. For your convenience, we accept cash, checks, Visa, MasterCard, American Express, and Discover as payment options. If you have any questions about coverage and/or payment, feel free to ask in advance of services being rendered.