Thank you for allowing us to participate in your care. The following is our financial policy.
PAYMENT IS EXPECTED AT THE TIME OF SERVICE. IF YOU ARE UNABLE TO PAY
PRIOR ARRANGEMENTS MUST BE MADE BEFORE SEENG THE DOCTOR
For your convenience we accept cash, check, Discover, MasterCard and Visa.
There is a $25.00 charge for a returned check.
Regarding Insurances with which we participate:
Blue Ridge Dermatology Associates, P.A. will file a claim with your insurance company. You are responsible for your
co-pay, co-insurance and any deductible at the time of service. Please make sure the front of this form is completed
entirely & accurately, especially if you are not the employee of the company (Primary Insured) offering the insurance
coverage. Information regarding the employee (Primary Insured) is now required by insurance companies to process
Regarding ANY INSURANCE POLICIES requiring referrals:
Obtaining the referral for the correct dermatological problem is the patient’s responsibility. If a referral is not obtained
for the problem you wish to have addressed, the total cost of the visit is due at the time of service.
Regarding non-covered services:
Services which your insurance company determines are not medically necessary will not be reimbursed by your insurance
company. Payment in full is due at the time of service. Examples of such services are removal of skin tags, normal
moles and benign Keratosis.
General responsibility for payment:
You are responsible for payment of any office visits or procedures for which your company denies payment. We will
attempt to advise you when we think a procedure might be denied. However, it is sometimes not possible to predict
whether a company will reimburse prior to submitting the insurance claim. We advise, that prior to any procedure, you
check with your insurance company regarding reimbursement.
Regarding insurances that we do not contract with:
The total cost of the visit is due at the time of service.
Third party claims:
We do not bill other parties such as financially responsible parents or employers. When a minor is present for care, the
person presenting the minor is responsible for payment at the time of service.
If at any time you are concerned about the cost of services, you may ask to speak to someone in the business office to
discuss your issues.
MISSED APPOINTMENTS OR LATE CANCELLATIONS:
Please call at least 1 business day prior to your scheduled appointment to cancel or reschedule.
This helps us accommodate other patients. Please be aware that scheduled appointments
cancelled less than 1 business day prior to the designated time, or failure to keep a scheduled
appointment, may risk a charge of a $50 missed appointment fee ($100 for surgery or
50% of physician cosmetic procedure fee).
Your signature below indicates that you understand and accept this policy.