Dr. Kongsiri and the staff at Visage Dermatology would like to welcome you to our Practice. We strive to provide you with excellent medical care and our goal is to make your visits as convenient as possible.
By signing below you confirm that you have read this policy and understand that:
- It is your responsibility to inform our office of any address or telephone number changes.
- Your account is to be kept current-accordingly, all self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service-payable by cash, check, Visa, Discover or MasterCard.
- If you do not have your payment(s), your appointment may be rescheduled.
- You may be asked to schedule another appointment for issues other than the reason for your original appointment.
- A returned check will result in a service charge that ranges from $25 to $40. Any returned check over $800.00 will be subject to a 5% return fee. All future payments will be required to be in the form of cash or credit card.
- You will only be sent a statement if your balance exceeds $5 and you will only receive a refund if the credit amount is over $10. Credit balance less than $10 will remain on your account for future use. Requested refunds will be issued within 6-8 weeks from the date requested, if there are no pending insurance claims.
- Credit Card refunds will be refunded to the same method and card used, less a 5% credit card processing fee.
- There is a $25 charge for the completion of paperwork (ex: disability, FMLA, etc.).
- If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said balance, which may include collection agency fees up to 35% of your outstanding balance or $50.00 whichever is greater, court costs and attorney fees.
- Should you fail to provide 24-hour notice of your intent to not keep your appointment, we reserve the right to charge you a no show fee.
- COSMETIC APPOINTMENTS: We require a 48-hour notice for cosmetic appointments. Failure to notify the office within the 48 hour time frame will forfeit your deposit. If you have a package treatment a $100 cancellation fee will apply, we will charge the fee to the credit card that you have on file.
- After three no-show occurrences, the practice reserves the right to dismiss you from the practice.
We will submit your Insurance claims, however we must emphasize that as medical providers, our relationship is with you, not your insurance company. Although we attempt to verify your benefits with your insurance policy, please be advised this is only an estimate of your coverage based on the information given to us at the time of the inquiry. It is the insurance company that makes the final determination of your eligibility.
By signing below you confirm that you understand:
- It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified prior to your appointment. You are responsible for your office visit fees if you have not met your yearly deductible.
- If your insurance policy requires a referral from your primary care physician, it is your responsibility to obtain it. The referral must be faxed to our office prior to your appointment. Failure to obtain the referral may result in the cancellation of your appointment. If you are seen by a provider without a referral you are responsible for all charges.
- Not all services are a covered benefit with all insurance plans and it is your responsibility to be aware of what service(s) is being provided to you and if it is a covered benefit. You are responsible for any non-covered charges not payable by your insurance policy.
- Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered.
- I hereby authorize Visage Dermatology, to store the last four numbers of my credit card account for payments owed to my account for services rendered at the office. I understand that my credit card will not be charged without authorization.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we urge you to contact us for assistance in the management of your account. If you have any questions about the above information, please do not hesitate to ask us.
I have read and understand the above Financial Policy and agree to meet all financial obligations.