- That copays are due at the time of service. Four Seasons Dermatology (FSD) accepts cash, checks, MasterCard, Visa, Discover, and American Express as forms of payment.
- That if I have a deductible, FSD will collect $100 as a down payment at the time of service or FSD will retain a credit/debit card on file to collect my balance due after insurance has processed my claim.
- That Medicare and other payors require FSD to maintain my signature on file authorizing FSD to file claims and receive payment for claims.
- That FSD will attempt to verify my insurance benefits before my appointment and that providing accurate information is my responsibility. It is my responsibility to know if my insurance requires a referral or prior authorization.
- That FSD cannot guarantee how my insurance will process any claim and that I am responsible for anything my insurance does not pay for. If my insurance later pays, FSD will reimburse me any overage.
- That cosmetic services are not covered by insurance and that I must pay for these treatments at the time of service. FSD maintains a fee schedule for cosmetic services, and I can get more information about rates for specific procedures, prior to treatment, from FSD’s billing staff.
- The dermatology providers of FSD do not participate with any Medicaid programs. Therefore, all services (includes prescriptions) rendered will NOT be submitted to any Medicaid insurance. If the patient and/or beneficiary wish to receive service from any of the providers at FSD, I accept full financial responsibility for these service(s).
- That I will receive bills for pathology services from the provider of those pathology services in addition to any fees from FSD.
- That there is a $50 charge for missed dermatology appointments and $100 charge for missed surgical appointments unless 24 hr notice is given.
- If I pay by check and my bank declines to pay, FSD will charge an additional $25 fee that will be my responsibility.
- If I am experiencing a financial hardship, FSD will arrange a payment plan with me. Failure to meet my responsibilities may result in placement with a collection agency. Delinquent accounts must be resolved before scheduling any future appointments.
By signing this form, I consent to treatment which may include examinations, diagnostic tests, procedures, and/or other therapies to effectively diagnose and treat my medical conditions. I agree to assign payable benefits from my insurance and/or third-party payor directly to FSD. I authorize the release of medical records as required by my insurance carrier. I understand that I am responsible for all charges for which my insurance declines to pay. I am also providing consent to be contacted via phone, US Mail, e-mail, or text message until I revoke these permissions.
Please note that if you are more than 10 minutes late for your appointment, your appointment may need to be rescheduled.