Thank you for choosing Academic Dermatology as your healthcare provider. We are committed to providing the best dermatological care possible. Please understand that payment of your bill is considered a part of your treatment. The following statement explains our Financial Policy. We ask you to read, sign, and return this to us prior to your treatment.
We participate in most insurance plans. As a courtesy, we will process and file your insurance claims. We require that the guarantor, the person who is financially responsible, is personally liable for all balances not covered by insurance including applicable co-pays, co-insurance and deductibles, for each visit. It is your responsibility to understand and comply with any predetermination of benefits or referral requirements. Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered medically necessary under your insurance plan. In the event of non-coverage, the guarantor is personally financially responsible for any non-covered service fees.
Non-covered Medical Services and Self Paid Medical Services
For services that are not covered by insurance and self-paid medical services, the practice requires payment of 100% of the total charges at the time of service.
Unless canceled at least 24 hours in advance, a fee of $50.00 will be charged to the patient for missed appointments and for late cancellations. This fee is not covered by your insurance and it will be your responsibility to pay this fee before your next visit. New patients who miss or cancel appointments will also be held to this policy. We understand that circumstances may arise which could result in a missed appointment or canceling the same day. Should such a circumstance arise, please contact our office to inquire about the possibility of waiving this fee. Subsequent missed or same day canceling of an appointment will result in the $50 charge being applied that must be paid before any future appointments may be made. Please help us to serve you better by keeping scheduled appoints, please call Academic Dermatology promptly if you are unable to attend an appointment. This will allow the time to be given to another patient who may be in urgent need of treatment. We reserve the right to terminate the physician-patient relationship and dismiss patients from our practice after two missed/cancellation appointments within a twelve-month period.
Cosmetic Deposit and Cancellation Policy
All cosmetic consultations are $150.00. Should you choose to schedule a cosmetic procedure; a $50.00 scheduling fee will be charged. If you choose to cancel your appointment and do not wish to reschedule, you must contact us at least 24 hours prior to your scheduled appointment time in order to receive a full refund. The cancellation must be verified with one of our schedulers. This policy also applies to all future cosmetic appointments, and for that reason, we will keep this credit card number on file.
Payment by Check
Your check must include your name, address, home and work phone number. There will be a check fee of $30.00 for all returned checks.
Payment for co-pays is expected at the time of service. If co-pay balances are not paid on the date of service, a $25.00 fee will be charged to your account. This fee is not covered by insurance so it will be the guarantor’s personal responsibility.
Past Due Accounts
Overdue accounts, past 90 days will be referred to Advantage Collection Professionals. Any legal fees that we pay to secure past due balances will be added to your account.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly to arrange a plan for payment. We will allow you 30 days to pay any balance remaining after insurance payment. If received after that time, your account will accrue interest at the rate of WSJ Prime plus 1.5%. If you have any questions about the above information, or any uncertainty regarding your insurance coverage, please do not hesitate to ask us. We are here to help you.