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Financial Responsibility Form

  • We at NY Medical Skin Solutions value you as a patient and appreciate that you have trusted us with your healthcare needs. As you know,there are charges for each of the medical care services that we provide to you. Be aware that although our office may participate with your insurance company, coverage levels vary widely with each individual policy and payment is not guaranteed by your health
    insurance. Since you are ultimately responsible for payment of the services provided to you, it is our policy to obtain and securely store your credit card information. This information is kept as part of your medical record and as such is subject to federal regulations pertaining to the security of medical records.

    Your health insurance policy is a decision made between you and your employer or insurance company, not our office. We strongly advise that you review your policy to be educated as to what is covered and what your level of responsibility is. When a claim is submitted on your behalf, our office and you will receive and “Explanation of Benefits” (EOB) in the mail. This details the care you received and the payment made by your insurance plan and what your responsibility (if any) will be. You should review this document carefully and call us to make any payment that is owed when you receive it. Typically, you will receive your statement before we receive one. Once we receive this statement, we will then proceed to charge your credit card on file and mail/email you a notice of payment received.

    In providing credit card information and signing below, you authorize payment to NY Medical Skin Solutions for any amounts due that are not covered by your health insurance. This includes but is not limited to co-payments, con-insurance, deductibles, and/or uncovered services. Services that may not be covered under some plans include, but are not limited to: acne, injections, wart treatment, office visits for benign conditions, and cosmetic procedures, “surgery” as defined by the insurance company (which sometimes includes “acne surgery”), any service for which a referral or prior authorization was not obtained, or any service performed and not billed to your current insurance due to failure to provide current information on the date of service or in a timely fashion. The physician can provide you with the proper procedure and diagnosis codes for any service you wish to clear with your insurance company first to assure coverage if you so choose. Please be aware that these services will then be performed at your next visit.

    Also, be aware that we do not send multiple billing statements. Accounts that are not paid in full within sixty (60) days are automatically forwarded to collections. By completing this form, it ensures that this does not happen and prevents negative items from being reported to the credit reporting agencies, we instead for your convenience are able to bill your credit card that is on file.

    *I am further aware that there is a cancellation/no show policy. If I do not show or cancel my scheduled appointment with less than 24 hour notice to the practice, I understand that I will be billed a $50.00 non-refundable fee.

  • *I also understand that my insurance MAY require me to have a referral in place prior to seeing the physician or physician assistant. If I do not submit the correct required referral at the time of my visit, I understand I will be billed for the cost of services rendered during my visit, for which my insurance will not cover without a correct referral.
  • Credit Card Authorization

All Co-pay and deductibles are to be collected at the time of service.

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