Financial Policy
& Office Procedures

Dear Patient,

We appreciate your confidence in choosing Premier Dermatology, PLLC for your skin care needs. Please take a moment to review our financial policy so that you understand your responsibility regarding the charges for the services rendered to you by this office. We require you to read and sign our electronic version of this document prior to receiving treatment.

When asked, and as a courtesy to you, we will try to give you general guidelines about what your insurance policy might cover. Since medical insurance is an agreement entered into by you and your insurance carrier, you are ultimately responsible for knowing the specifics of what your policy covers and for notifying us when your insurance changes.
Failure to update us with changes in your insurance coverage may result in a denial of coverage from your carrier, and in that case, you would be responsible for payment of the entire amount due.
Payment is due at the time of service.
Acceptable forms of payment are cash, check, VISA, MasterCard, Discover, and American Express.

IN-NETWORK

For those patients covered by insurance plans with which we are participating providers, we will determine your copay due at the time of the visit. Co-payments and co-insurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due at the time of service. We will file the insurance claim to the insurance company.

OUT OF NETWORK

In the event that your insurance coverage changes to a plan with which we are not participating providers, we will require payment in full at the time of service and we will file your claim to the insurance company as a courtesy. Any charges that are not paid by your insurance company are your responsibility.

SELF-PAY

Self-pay or uninsured patients are responsible for payment at the time of service.

If we participate (i.e. are contracted) with a commercial insurance plan under which you are covered, we will bill the carrier for the charges that relate to COVERED services rendered. This means that services for the removal of benign lesions, which are not likely covered by insurances (for example: skin tags, seborrheic keratoses, telangiectasia, and other COSMETIC procedures), will be paid at the time of service. We will bill both your primary and secondary insurance plans for covered services under the contracted plans. Complete insurance information, including referrals from other providers, for primary and secondary insurance coverage(s) must be made available to the Practice including all identification, benefits cards/documents, and any other information required by your insurance carrier, for accurate filing of claims. In the event that we are not aware of a charge that is not covered by your plan, you will be billed the balance after we obtain the denial from your insurance.

You are responsible at the time of service for payment of: co-payments, and/or charges for non-covered or cosmetic services.

ABOUT CO-PAYMENTS

If you are an enrollee of a managed care plan (HMO or PPO) that we are contracted with, you are required to pay the co-payment each time you are seen, (including follow-up appointments) and it must be paid before you see the physician. If you are not prepared to pay the co-payment, the visit must be rescheduled. If you do not know your co-payment, we will collect $30 for your co-payment at check-in.

ABOUT REFERRALS

If you are enrolled in an HMO or other plan which requires a referral from your primary care physician, you must have the referral with you OR the referral must have been sent to us in advance of your visit in order to be seen by the physician. You are responsible for obtaining you own referral (from your primary care physician), FOR EVERY VISIT.

MEDICARE PATIENTS

We are a Medicare participating provider. We will bill Medicare. You will be responsible at the time of service for co-payments and charges for non-covered or cosmetic services. If you have Medicare as well as a secondary coverage with a commercial plan or is an insurance company with which we have no contract, we will file a claim to your secondary/supplemental carrier. If no payment is received from your secondary/supplemental carrier within 60 days after we file a claim, you will be sent a bill, and you will be responsible for the balance.

FOR NON-MEDICARE PATIENTS

If you have insurance coverage with an insurance carrier which we have no contractual relationship, please note the following: you are responsible, at the time of service, for payment of all services.

You will receive forms at the time of service which you can use to bill your primary and secondary insurance plans for any reimbursement that may be due from you under your policy. Please understand that if we do not have a contract with your plan, we are not obligated to adjust our charges based on your plan’s coverage or benefits.

CANCELLATION POLICY

We recognize that everyone’s time is valuable, so we make every effort to maintain the scheduled appointment times. If you arrive more than 10 minutes late for your scheduled appointment, you may be asked to reschedule.

YOUR APPOINTMENT TIME IS RESERVED EXCLUSIVELY FOR YOU. WE REQUEST THAT YOU ALLOW ONE HOUR TO BE IN OUR OFFICE. WE WILL CHARGE $75 ($125 FOR SURGERY) FOR EVERY MISSED APPOINTMENT/ APPOINTMENT CANCELED WITHOUT 24 HOURS ADVANCE NOTICE.

COSMETIC CANCELLATION POLICY

Should you need to cancel or change the date of your cosmetic procedure; we require at least 24 HOURS NOTICE as a courtesy to other patients seeking our services. Any cosmetic procedure canceled without 24 hours’ notice will incur a $125 CANCELLATION FEE.

RX REFILLS

Please contact your pharmacy for any refill requests. They will electronically contact the office for approval. Allow up to 48 business hours for refills to be completed. Refills received after 3:00 PM on Friday will be considered part of Monday’s business.

CREDIT CARD SALES

All credit card sales for products and services are final. We do not accept returns or exchanges.

Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.