Insurance Plan provisions require HMO/PPO patients present a current insurance card at time of service, other- wise payment is due in full, and no adjustment will be made later. If we are not a participating provider with your insurance plan, a claim will not be filed and patients will be responsible for full payment at the time service is ren- dered. We will gladly discuss your proposed treatment and answer any questions relating to your insurance. You must realize, however, that:

1. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract.
2. Our fees are generally considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This applies only to companies that pay a percentage (e.g. 50% or 80%) of “U.C.R.” “U.C.R.” is defined as usual, customary, and reason- able. This statement does not apply to companies that reimburse based on an arbitrary “schedule” or fees, which bear no relationship to the current standard of cost and care in this area.
3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. In the event your insurance carrier does not cover your service, you will be responsible for payment of that service and will be billed accordingly.

We must emphasize that, as a medical care provider, our relationship is with you, not your insurance company. While filing insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the service is rendered. We do not routinely research why an insurance carrier has not paid, or why it paid less than anticipated. We realize that temporary financial problems may affect timely payment on your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your ac- count.

No-shows A patient will be considered a “No-show” if they are more than 10 minutes late for their scheduled ap- pointment time or do not cancel their appointment at least 24 hours prior to their scheduled visit. We understand that appointments can sometimes not be kept, however, we request that if you cannot keep an appointment for any reason, kindly call us at least 24 hours in advance so that someone else may have your appointment time. Many patients need to see one of our providers as soon as possible, and it is not fair for a patient to be denied treatment because another patient did not call to cancel their appointment in advance.

I authorize the release of information relating to all claims for benefits submitted for dependents or myself and agree that my signature below authorizes claims submitted for services rendered. I authorize my insurance company to pay and assign directly to Dermatology Arts all reimbursement benefits payable under my insurance policy.

I understand that I am financially responsible for all charges incurred, and if the insurance does not pay within 45 days, the balance is due from me. If my insurance is an HMO and I do not present a referral from my PCP (primary care provider) at the time of service, I agree to be responsible for any charges denied by my insurance company due to non-presentation of a referral from my PCP. I hereby authorize Dermatology Arts to release by mail, telephone, and/or fax any medical or incidental information that may be necessary for either medical care or processing applications for financial benefits.

I certify that the information given by me is correct. I understand that fees for all the services provided by Dermatology Arts are due at the time services are rendered unless other arrangements have been made and that I am in agreement with the financial and privacy policies currently in effect.

I authorize Dermatology Arts, PLLC to release my medical information to the person(s) listed below. I understand that the person(s) named on this authorization will be given access to obtain results/ information on my behalf. I authorize the person(s) indicated to pick-up materials pertinent to my medical care.