In order to establish an optimal relationship and avoid misunderstanding and confusion regarding our payment policies, our staff is trained to inform you of the financial payment policies of this office. Payment is required at the time that services are rendered. You will be provided with a good faith estimate of charges. We accept payment in the form of Cash, Credit Card, Debit Card.
- I understand it is my responsibility to cancel my appointment with Lehman Advanced Dermatology no later than 24 business hours prior to the appointment date and time or 72 business hours prior to the scheduled surgical date and time, or I may be billed $50 for the missed appointment and $150 for a missed surgery.
- I understand that it is my responsibility to present accurate and current insurance coverage information at the time of check-in. At that time, I will be asked to pay for all services not covered,
deductible amounts, co-pays, past due balances, as well as balances due to invalid insurance information. For patients with HMO coverage or other third party insurance that requires authorizations, I will be held responsible for payment if the referral authorization is not provided at the time of service. I, as the patient or responsible party for the patient, agree to be responsible for charges or services referred to another physician or laboratory by any physician or practitioner of Lehman Advanced Dermatology, PLC.
- I consent to the release of medical information necessary to process any insurance claims. I also consent to the release of medical information to other physicians who may participate in my treatment.
- I understand that failure to make payment when due is the basis for legal action, and agree to pay all reasonable costs of collection, including attorney’s fees.
- I understand it is the policy of Lehman Advanced Dermatology, PLC, to collect any outstanding balance before additional services are rendered.
- I understand Lehman Advanced Dermatology, PLC, does not accept personal checks.
- I authorize and request that payment by an authorized insurance company be made payable to Lehman Advanced Dermatology, PLC, on my behalf for the services furnished to me by the physician(s)/practitioner(s) of Lehman Advanced Dermatology, PLC.