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Welcome and thank you for choosing A & G Dermatology for your dermatologic care. We are committed to providing you with the highest quality medical care possible in a cost effective manner. Our professional fees have been determined through careful consideration in addition to being reasonable and customary within our geographical area. We are pleased to discuss with you any questions you may have concerning a bill.
Payment in full is due at the time services are rendered. As a courtesy to our patients, we accept cash, personal check, money order, Debit, Visa, MasterCard, Discover, and American Express.
We also provide our patients the ability to pay for their accounts over the phone at local: (773)237-7546.
In order to achieve our goal of providing you with the best care possible, we need your assistance and your understanding of our financial policy:
Our Office Hours are:
· Monday and Wdnesday: 10am-5 pm
· Tuesday: 10am-7 pm
· Thursday: 10am- 6:45pm
· Friday: 10am- 4pm
· Our answering service is available after hours for patient emergencies
Things to bring with you to EACH appointment:
· Health Insurance Card(s)
· Drivers License
· Method of Payment
Appointments:
· Please arrive for your appointment 15 minutes early to allow for registration into our electronic medical record system [EMR].
· If more than 15 minutes late for your appointment, you may be marked as a No Show and will need to reschedule your appointment.
· It is your responsibility to verify that the physician is currently under contract with your insurance plan and that you have obtained all necessary referrals BEFORE your scheduled appointment. (Failure to confirm this may result in your responsibility for any and all charges.)
· Please inform the receptionist of any demographic changes (phone number, address, insurance information, etc.). Failure to notify us immediately of changes in demographic information, financial status and/or insurance coverage may result in you being responsible for any services not covered by your insurance carrier.
Missed or Cancelled Appointments and other fees:
· All co-pays are due at the time of service.
· There will be a fee of $25 for any returned checks to our office.
· All balances are due prior to any further service provided by our office.
· Extended appointments require 48 hour notice of canceling, or $75.00 deposit required to reschedule.
“In Network” vs. “Out Of Network” Insurance
· Your insurance coverage and benefits are a contract between you and your insurance company and therefore all disputes must be handled between you and your insurance company.
· Remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment.
· Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. The extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient’s record.
· We are contracted with multiple insurers to accept assignment of benefits.
· If you have insurance coverage under a plan with which we do not have a contract, you will be treated as a self pay patient.
· We are required to file with your primary insurance carrier only. As a courtesy to our patient, we will file a claim with your secondary insurance.
Payment in full is due at the time services are rendered:
· Co-pays and co-insurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due during the check-in process. Failure to produce payment at check-in may result in your appointment being rescheduled.
· Any amount not covered by the insured/patient’s insurance is due within 30 days of the time of service.
· Any outstanding balance may incur a $10 monthly statement late fee in addition to the initial balance.
· As a courtesy to our patients, we gladly accept cash, check, money order, Debit, Visa, MasterCard, Discover, or American Express.
· Failure to pay balances may result in discharge from the practice.
Keeping a credit card on file:
· Please sign our Patient Pay Easy Consent form in order to keep a credit card number on file (the same process you would go through for hotels, rental cars, etc.) to be used for any unpaid balances. (Optional)
Medicare Patients:
· Please make sure you have a full understanding of your benefits and what might be your responsibility if not covered by your insurance plan.
· Medicare requires that we provide patients with a written notification whenever it is likely that you will be responsible for a bill.
Minor Patients:
· The parent(s) or guardian(s) accompanying a minor are responsible for providing current insurance information for the minor as well as the payment in full for services provided.
· Parent(s) or guardian(s) must have an Authorization for Medical Treatment form signed each time a minor arrives unaccompanied for an appointment.
· In compliance with HIPAA regulations, we are unable to discuss any details of services rendered or to produce an itemized bill for any parties that are not the patient, parent/guardian unless otherwise documented.
· Both parents/legal guardian(s) are responsible for payment for services rendered to the minor patient. A copy of this financial policy and all statements will be provided to each parent if living in separate residences.
Lab/Hospital Charges:
· Any service(s) provided by a lab or hospital is a contract between you and that lab or hospital. Any dispute with that lab or hospital should be handled with that lab or hospital and is not the responsibility of our practice.
· It is your responsibility to know which procedures your insurance will and will not cover at these facilities and to request an Explanation of Benefits (EOB) from your insurance carrier.
Collections and Outstanding Balances:
· The provider reserves the right to add a $10 monthly statement late fee on any account that has an unpaid balance.
· Any outstanding balance after 60 days of the date of service may be referred to an outside collection agency. If this account is assigned to an attorney for collection and/or suit the prevailing party shall be entitled to reasonable attorney’s fee and costs of collection.
· Patients with unpaid delinquent accounts or accounts which have been sent to collections may be discharged from our practice.
Payment Plans:
· Our office will be happy to work with you in order to pay any balance due to our practice.
· Please contact our billing department to work out a payment plan with our practice.
· Please allow 5 mail days prior to each due date for each payment to be received by our practice.
· Please mail all payments to our office: Or over the phone @:
1733 N. Harlem Ave (773)237-7546
Chicago, IL 60707
Refunds:
· Refunds are issued to the appropriate party.
· Patient refunds will not be processed until all active or past due charges are paid in full.
Medical Records:
· Your medical records will be held in the strictest confidence. If you request a copy of your records to be sent to another physician or to yourself, a written authorization will be required, a professing fee, and additional costs may apply. Only the records requested will be forwarded.
Cosmetic/Elective/Esthetician Procedures:
· By definition, these procedures are not covered by insurance companies; and this office does not submit claims on their behalf. Payment in full is required on the day of the scheduled procedure.
· We fully comply with the federal standards regarding privacy and security of your personal health information. (HIPAA)
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