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Appointment Request

Your request will be delivered immediately to our practice staff and processed promptly during normal business hours. In the comment section you can provide any details you would like to share (preferred office location, times preferred and days of the week preferred, etc).

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Medical Billing

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Office Policies

Patient Payments

You should expect to make some payments either before your office visit or at the time services are rendered. As a patient you must make your co-payment, deductibles and coinsurance payments at the time you receive care.

Your payment options are as follows:

For Cosmetic or Non-Covered Services: Payment Required at Time of Service

For Medical or Covered Services:

Pay at time of service: Payment at Time of Service

Bill my insurance first: Payment up to 45 days later

The amount of your patient office visit fee is based on your insurance plan, if any, and whether the services to be provided are covered services. You should also expect to pay fees for procedures that are not covered by your insurance; including certain cosmetic services and skin care products. You may pay for these additional procedures, services and products at the conclusion of your appointment.

Insurance

Before your visit, you should check with your insurance company to be sure that you have the proper documentation with you when you arrive (health insurance card, member id number, etc) and are aware of your co-payment, co-insurance, and deductible requirements and any insurance restrictions.

If we are a participating provider on your insurance plan, as a courtesy we will file a claim with your insurance company. If you elect the

Bill my insurance first payment plan and request that we bill your insurance company first you must supply us a copy of the credit card that will be billed for any outstanding amounts; provide consent to charge the credit card and supply certain other information items to facilitate a complete filing of your insurance claim. Based on the Explanation of Benefits (EOB) response from your insurance company we will bill your credit card the amount that is your responsibility and send you a copy of the receipt reflecting the charges. We will not send you a bill or invoice. Your EOB from your insurance company will serve as your invoice.

In the event that your insurance company denies payment for any reason, you or your guarantors are responsible for payment of all outstanding charges for services rendered. We will generally, allow 45 days from the time we submit a claim to your insurance company for the insurance company to acknowledge the claim, make payment, or deny the claim. On the 46th day if we have not received payment, the amount is
due in full by you and we will charge the credit card you have on file with us.

If you are a subscriber of one of the HMO plans that City of Angels Dermatology participates you may select the Pay at time of service payment option. Your total responsibility for covered services is your co-payment and shall be paid prior to services are rendered.

If we are non-participating provider on your insurance plan, you are expected to pay in full at each office visit. We will supply you with an itemized form that you can use to submit to your insurance provider for reimbursement.

Allowable Forms of Payment

We accept the following forms of payment for all fees.

· Cash

· Check

· Credit Card – Visa, MasterCard, Discover, Debit Card

Returned Check Fees

If your check payment is returned you will be assessed a returned check fee of $35 in addition to the office service fee.

Charges for Broken Appointments

If you are unable to make your scheduled appointment we ask that you notify us at least one business day prior to scheduled appointment.

Please call us during normal business hours of

9:00 am and 5:00 pm.

If you are unable to make your appointment and neglect to notify us at least 24 hours in advance, you will be billed accordingly:

$25 for office visits and $50 for scheduled surgery or procedure.

THANK YOU FOR TAKING THE TIME TO READ THIS

POLICY STATEMENT. WE VALUE OUR RELATIONSHIP

WITH YOU AND SEEK TO ENSURE THAT OUR POLICIES

ARE FAIR AND CLEARLY COMMUNICATED. WE HOPE

THIS DOCUMENT ANSWERS SOME QUESTIONS FOR

YOU. IF YOU HAVE ANY MORE QUESTIONS

REGARDING THESE MATTERS, PLEASE LET US KNOW.

City of Angels Dermatology

Financial Policy

Patient Payments