Dr. Kongsiri and the staff at Visage Dermatology would like to welcome you to our Practice. We strive to provide you with excellent medical care and our goal is to make your visits as convenient as possible.
By signing below you confirm that you have read this policy and understand that:
- It is your responsibility to inform our office of any address or telephone number changes.
- Your account is to be kept current-accordingly, all self-pay or insurance co-payments, co-insurances and deductibles will be collected at the time of service-payable by cash, check, Visa, Discover or MasterCard.
- If you do not have your payment(s), your appointment may be rescheduled.
- You may be asked to schedule another appointment for issues other than the reason for your original appointment.
- A returned check will result in a service charge that ranges from $25 to $40. Any returned check over $800.00 will be subject to a 5% return fee. All future payments will be required to be in the form of cash or credit card.
- You will only be sent a statement if your balance exceeds $5 and you will only receive a refund if the credit amount is over $10. Refunds will remain on your account for future use. Requested refunds will be issued within 4-6 weeks from the date requested, if there are no pending insurance claims.
- There is a $25 charge for the completion of paperwork (ex: disability, FMLA, etc.).
- Any unpaid balances older than 30 days may be subject to 1.5% interest per month.
- If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of said balance, which may include collection agency fees up to 35% of your outstanding balance, court costs and attorney fees.
- Should you fail to provide 24-hour notice of your intent to not keep your appointment, we reserve the right to charge you a no showfee. We require a 48-hour notice for cosmetic appointments.
- After three no-show occurrences, you will be dismissed from the practice.
If you have health insurance coverage:We will submit your claims, however we must emphasize that as medical providers, our relationship is with you, not your insurance company. Although we attempt to verify your benefits with your insurance policy, please be advised this is only an estimate of your coverage based on the information given to us at the time of the inquiry.
By signing below you confirm that you understand:
- It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified prior to your appointment.
- You are responsible for your office visit fees if you have not met your deductible for the year.
- If your insurance policy requires a referral from your primary care physician, it is your responsibility to have that referral faxed to our office prior to your appointment.
- Not all services are a covered benefit with all insurance plans and it is your responsibility to be aware of what service(s) is being provided to you and if it is a covered benefit under your insurance policy.
- You are responsible for any non-covered charges not payable by your insurance policy.
- Although filing your insurance claims is a courtesy extended to you, all charges are always your responsibility from the date services are rendered.
- We allow our patients 60 days to pay for the patient- owed part of the cost of their medical services.
We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we urge you to contact us for assistance in the management of your account. If you have any questions about the above information, please do not hesitate to ask us. We are here to help you.
I have read and understand the above Financial Policy and agree to meet all financial obligations.