BASIC POLICY

Payment of services is due in full at the time services are provided in our office.

FOR PATIENTS WITH INSURANCE

We bill most insurance carriers for you if proper paperwork is provided to us. We will also bill most secondary insurance companies for you. Copayments and deductibles are due at the time of service. Since your agreement with your insurance carrier is a private one, we do not routinely research why an insurance carrier has not paid or why it paid less than anticipated for care. If an insurance carrier has not paid within 60 days of billing, professional fees are due and payable in full from you.

MEDICARE PATIENTS

We will bill Medicare for you. We will also bill secondary insurance carriers for you. All copayments or deductibles are due and payable at the time service is provided. Your signature on the accompanying Acknowledgement Signature Form signifies that the following has been read and understood:

I request payment of authorized Medicare benefits be made either to me or on my behalf to Las Vegas Dermatology^® for any services furnished me by the listed provider/supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services.

I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in Item 9 of the HCFA-1500 form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency show. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and the deductible are based upon the charge determination of the Medicare carrier.

GOVERNMENT ASSISTANCE INSURANCE PATIENTS

All government assisted insurance patients must provide a current, valid Nevada Medicaid Card or Paperwork before being seen. SURGERY FEES All co-pays, deductibles, and payments for non-covered surgical procedures are due prior to your surgery. Prior authorization may be required by your carrier.

NONCOVERED SERVICES

Any care not paid for by your existing insurance coverage will require payment in full at the time services are provided or upon notification of insurance claim denial.

PERSONAL INJURY CASES

This office does not bill for auto accident or other liability or lawsuit-related cases. You are responsible for payment at the time of service. We do not accept liens.

WORKER’S COMPENSATION

If your injury is work-related, we will need to be informed of this before being seen. YEARLY HEALTH CHECKS Periodic preventive health checks may or may not be covered under your health insurance policy; however, they may be required by your physician.

MISSED APPOINTMENTS

In fairness to other patients and the doctor, we required at least 24 hours notice to cancel appointments. You may be charged for missed appointments or dismissed from the practice.

The patient is ultimately responsible for all professional fees.