Patient Financial Responsibility Form

Patient’s Financial Responsibility

We at (________) 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 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. We 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 will

receive an “Explanation of Benefits” (EOB) in the mail. This details that 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 (________) for any amounts due that are not covered by

your health insurance. This includes but is not limited to co-payments, co-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.

Accounts that are not paid within (_____) 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 $(_____) non-refundable fee.

(Sign here) ___________________________________________________________ Date: ___________________________________

*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.

(Sign here) _________________________________________________________ Date: _________________________________

Credit Card Authorization

PATIENT’S NAME: ______________________________________________________________ DATE: _________________________

PARENT/LEGAL GUARDIAN’S NAME: (IF APPLICABLE) _____________________________________________________

NAME ON CREDIT CARD: _______________________________________________________________________________________

CREDIT CARD TYPE: AMERICAN EXPRESS

VISA

MASTERCARD

DISCOVER

CARD NUMBER: ______________________________________ EXP DATE: _____________ BILLING ZIP: _________________

SIGNATURE: ___________________________________________

This content is not offered as, and should not be relied on as, legal advice. You should consult an attorney for advice in specific situations and to ensure the content is up to

date.