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Name ________________________________________________ Date of Birth _____________________________
FINANCIAL POLICY
1.
W e request a 24 hour cancellation notice. Failure to cancel an office visit will result in a $25
fee. Failure to cancel a surgical or cosmetic procedure will result in a $75 fee.
2.
Paym ent is due at the time of service. It is your responsibility to pay for any deductibles, co-
payments, or non-covered/cosmetic services on the day of your appointment. We accept Visa,
MasterCard, debit, checks, and cash. There is a $25 charge for checks returned for insufficient funds.
3.
Keep in mind that your insurance policy is basically a contract between you and your insurance
company. However, you are ultimately responsible for the payment of services. As a service to you, we
will file your insurance claim if you assign the benefits to the doctor—in other words, if you agree to have
your insurance company pay the doctor directly. If your insurance company does not pay the practice within
60 days, you are responsible for paying any outstanding balances.
4.
If we are not contracted with your insurance carrier or if you do not have insurance coverage, you
are responsible for payment in full at the time of service.
5.
Not all insurance plans cover all services. Although policies vary among insurance companies and
plans, most do not cover cosmetic services or removal of benign skin growths. In the event your insurance
plan determines a service to be “not covered,” you will be responsible for the complete charge.
AUTHORIZATIONS
1.
I have read and understand the practice’s financial policy and I agree to be bound by its terms.
2.
I authorize the release of medical information to my primary care or referring physician, to
consultants if needed, and as necessary to process insurance claims and prescriptions.
3.
I have read and understand the Notice of Privacy Practices from Roseville Dermatology, Inc.
4.
I authorize Roseville Dermatology, Inc. to take digital photographs for my medical record only if
medically necessary.
5.
I authorize my providers and staff here to view my external prescription history via the RxHub
service.
Signature: ______________________________________________
Date: ____________________

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