Financial Statement:
     Thank you for choosing our office for your care.  We appreciate the opportunity to serve your health care needs and look forward to getting to know you.  I f you have any questions or concerns, please feel free to discuss these with our staff.  Our goal is to provide personalized, medical healthcare in the most cost-effective manner.  This form was developed to explain and clarify our financial policies.

Standard Payment Policy:
      Payment for our office visits, if out-of-network, is due at the time services are rendered. For your convenience, we accept VISA, MASTERCARD, CASH, and CHECK. We will provide you with an itemization of charges that you may submit to your insurance carrier for reimbursement of fees.
     For Medicare patients, our office accepts Medicare assignment and files claims with Medicare. Medicare patients are responsible for any co-insurance and deductible amounts. Medicare patients must present their Medicare card at the time of registration unless they have changed to an alternative Medicare product. In that case we would need the card sent by that insurance company. We will file secondary insurance for Medicare patients only.
     In you are an HMO/PPO (managed care) patient of a plan in which we participate, our office has agreed to accept the plan’s fee schedule and file the claim with your insurance company. HMO/PPO patient are responsible for co-pays and deductibles at the time of service and must present their insurance card at the time of registration. Patients are also responsible for obtaining a referral number from their primary care physician.
     We make every effort to seek insurance reimbursement on covered services. Filing insurance is a service we provide to you; however, insurance is a contract between you and your carrier. Once your insurance company has paid, you will receive a bill for any remaining balance on the account.

Collection Efforts:
     We work with you to make payment arrangements. If these efforts do not result in a resolution of the account, the account may be referred to a collection agency and the local credit bureau.

Returned checks:
     A service fee of $25.00 is charged on all returned checks. You will be given the opportunity to send the total of the check plus the $25.00 fee in the form of cash, cashier’s check, or money order on a timely basis.

Missed or cancelled appointments:
     In you do not appear for your appointment, or if you cancel your appointment with less than 24 hours notice, you will be billed a $25.00 “missed appointment” fee. If the appointment was for a surgical or cosmetic procedure the fee is $50.00.

“Not Medically Necessary” or “Cosmetic” Procedures:
     Insurance companies have instituted restrictions on procedures and have designated these as “not medically necessary”. A list of procedures that commonly fall into this category are listed below:

• Removal of benign lesions, including moles, skin tags, cherry or spider angiomas, lentigos, cysts, and seborrheic keratoses by any procedure.

• Glycolic acid peels

• Microdermabrasion

• Surgery to repair a torn ear (due to earrings)

• Sclerotherapy for leg veins

• Destruction of blood vessels of the face

• Botox or Fillers injections done on the face.

• Laser Hair Removal

      If you elect to continue with a procedure in this non-covered category, payment in full is required at the time the service is rendered. There is no reduction in our standard fee schedule for managed care or Medicare patients. Medicare patients will be required to sign a separate acknowledgement statement as required by Medicare guidelines. Our office does not file a claim with your insurance carrier when any of these procedures are performed.