Dermatology Practice Financial Policy Agreement

Patient Information

Name: _________________________ Date of Birth: _____________ Account #: ______________________ Date: ___________________

Financial Responsibility Agreement

1. Insurance and Payment Policy

• I understand that I am financially responsible for all charges, whether covered by my insurance or not
• I agree to present my current insurance card at each visit
• Co-payments and deductibles are due at the time of service
• If my insurance requires a referral, I must obtain it prior to my visit

2. Payment Terms

• Payment methods accepted: cash, check, credit cards (Visa, MasterCard, American Express)
• Outstanding balances are due within 30 days of statement date
• A $35.00 fee will be charged for returned checks
• Payment plans are available upon request and approval

3. Cosmetic Services

• All cosmetic procedures must be paid in full at time of service
• Cosmetic services are not covered by insurance
• Deposits may be required for certain procedures

4. Cancellation Policy

• 24-hour notice is required for appointment cancellations
• A $50.00 fee may be charged for no-shows or late cancellations
• Multiple no-shows may result in discharge from the practice

5. Insurance Claims

• We will submit claims to your insurance company as a courtesy
• You are responsible for knowing your insurance benefits and coverage
• Any denied claims become patient responsibility

Agreement

I have read and understand the financial policy above. I agree to comply with these terms and accept financial responsibility for services rendered.

Signature: _________________________ Date: _______________

Print Name: ________________________ Relationship to Patient: _______________