Your clear understanding of your Patient Financial Policy is important to our professional relationship. Carefully review the following information and return this form with your signature and today’s date. Please ask if you have any questions about our fees, our policies, and/or your responsibilities.

Insurance- When making an appointment with your physician, it is your responsibility to confirm with your insurance company that the physician is currently under contract with the plan. If your plan requires that you have a referral prior to seeing a specialist, please contact your primary care physician so that you have the referral at the time of your appointment. If you do not have your referral at the time of your appointment, you will need to reschedule your appointment, or choose to be seen without the insurance benefits and pay for your visit in full.

You are responsible for knowing your insurance benefit coverage. We will gladly file your insurance claim on your behalf. We allow 45 days from the date the claim is filed for the insurance company to pay. If the insurance company does NOT pay within this time, you will be responsible for the entire balance. We will not become involved in disputes between you and your insurance company regarding coverage and/or policy benefit criteria, i.e. deductibles, non-covered service, coinsurance, coordination of benefits, or pre-existing conditions. You are responsible for all co-payments and deductibles at time of service.

Check-In: Please bring your current insurance card with you to EACH visit. Without the insurance card, we will be unable to file your insurance, and you will be responsible for all charges for that visit. On follow-up visits you will be asked to verify all demographic and insurance information so that our records remain up-to-date.

Check-Out: Please be prepared to pay for the current visit as well as any past balances on your account. Payment and co-payments, deductibles, or fees for non-covered services will be required at the time of service. For your convenience we take cash, check, and all major credit cards.

Non-Covered Services: An Insurance Waiver may be required to acknowledge understanding of your responsibility for paying for non-covered services. In dermatology, there are many procedures that are considered by Medicare and private insurers as non-covered, including removal of skin tags, cosmetic treatment of spider veins, removal of whiteheads, as well as others. If you are coming in for a non-covered service, please be prepared to pay for the service in full.

Return Check Fees: Any returned check from the bank for non-payment shall result in the patient’s or Guarantor’s account being assessed a $25.00 fee per check.

Pathology Fees & Lab Tests: If your visit includes biopsies or lab tests these specimens are sent out for processing. You will receive separate billings from the laboratory performing the service. You are responsible to notify us if your insurance company requires particular labs for coverage of the processing.

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Pinnacle Dermatology and Skin Rejuvenation