Financial Responsibility: I understand that if I do not have health insurance, full payment is due at the time of service. I understand it is my responsibility to know my insurance policy coverage and benefits and to notify Restoration Dermatology of any insurance changes. A copy of the insurance card must be provided following any changes. I understand that I am responsible for any amount not covered by my insurance policy. I understand that payment is due on the date in which services are rendered, including copays, deductible or coinsurance amounts, and charges for cosmetic services. Routine, in-office procedures including biopsies, injections, and destruction of growths may be subject to my deductible or coinsurance. I agree to fulfill all policy provisions which my insurance company may require for payment. 

Managed Care (HMO) Plans or Health Select: I understand that it is my responsibility to obtain any and all necessary referrals if my plan requires one. Restoration Dermatology will strive to keep me informed of the status of any referral, but it is ultimately my responsibility to make the necessary arrangements through my primary care physician. I understand that failure to obtain a referral, if required by my insurance for coverage, will result in the full balance becoming my financial responsibility for any and all services received. 

Benefit Verification: I understand that the staff of Restoration Dermatology will make every effort to accurately verify my insurance benefits, but this verification is not a guarantee of payment by my insurer. I understand that I have a right to refuse any services before they are rendered. I understand that the final determination regarding my benefits and any amounts owed will be made by my insurer at the time of claim processing according to the provisions of the policy contract that I have with them. Any questions regarding insurance benefits for dermatology services may be directed to the front desk. 

Release of Information: I authorize the release of any medical information to my insurance company, Medicare and/or supplemental policy that is necessary for the processing of claims. I understand that this authorization may include the release of information regarding communicable diseases, such as Acquired Immune Deficiency Syndrome (“AIDS”) and Human Immunodeficiency Virus (“HIV”). 

Assignment of Benefits: I authorize the payment of benefits directly to the providers at Restoration Dermatology in all claims for services rendered. 

Medicare/Supplemental Benefits: If covered by Medicare and a supplemental policy, I request that payment of authorized benefits be made on my behalf. I hereby authorize Restoration Dermatology to release all information necessary to secure all payments or approval of benefits. 

Payment for Ancillary Services (Laboratory/Pathology): I understand Restoration Dermatology utilizes the services of outside laboratories for pathology (biopsies), microbiology (cultures) and blood chemistry. These laboratories will bill for services separately from Restoration Dermatology. I acknowledge that payments made to Restoration Dermatology are for services rendered by Restoration Dermatology and authorize the use of outside laboratories as deemed necessary and ordered by my doctor(s). I understand that this may result in a financial responsibility to the laboratory providing these diagnostic services. 

Worker’s Compensation: I understand that Restoration Dermatology does not accept Worker’s Compensation cases. 

Returned Checks: I understand that checks presented to Restoration Dermatology as payment for services rendered and subsequently returned by my bank for any reason as unpaid will be charged a returned check fee of $25. Balances must be handled by cash, credit card or money order. Restoration Dermatology reserves the right to represent returned checks electronically for their face value plus the returned check fee. 

Past Due Accounts: I understand that all outstanding accounts may be turned over to a collection agency after three statements and one pre-collection letter. I acknowledge that I must contact Restoration Dermatology before this time if I wish to make other payment arrangements.