Skin Solutions Dermatology

  
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Directions and Forms


HOW TO FIND US:

 

We are located at

500 Main Street, Suite 113 Ames Iowa

Main Street Station

Common Entryway with Hy-Vee Drugstore.

 

 
 

Financial Policy

Skin Solutions Dermatology PLC

 

The following payment policy explains our financial policies. A copy will be provided to you upon request.

1. Insurance. We participate with most major insurance plans including Medicare. If you are insured by a plan we do not participate in, payment in full is expected at each visit. Contact your insurance company with any questions you have regarding your coverage. This is your responsibility.

2. Co-payments and Deductibles. All co-payments and deductibles must be paid at the time of your visit. This is part of your contract with your insurance company. Failure on our part to collect co-payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.

3. Non-Covered Services. Please be aware that some of the services you receive may not be covered by your insurance plan. You must pay for these services at the time of the visit.

4. Proof of Insurance. All patients must complete our patient information form before seeing the physician. We must obtain a copy of your current insurance cards. If you fail to provide us with the correct insurance information in a timely manner, you are responsible for the balance of the claim.

5. Claims Submission. We have a billing service that submits your claims and assists you in any way we reasonably can to help you get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company. We are not party to that contract.

6. Coverage Changes. If your insurance changes, please notify us at your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 90 days, the balance will automatically be billed to you.

7. Nonpayment. If your account is over 90 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Please be aware that if a balance remains unpaid, we may refer your account to an outside collection agency and your immediate family members may be discharged from this practice. If this is to occur, you will be notified by regular and certified mail that you have 30 days to find alternative medical care. During that 30-day period, our office will only be able to treat you on an emergency basis. Please notify us if there are circumstances that do not allow you to pay your balance in full and we can make other arrangements with you. If we do not hear from you we will expect payment in full.

 

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary changes for our area.

Thank you for understanding our payment policy. Please let us know if you have any questions or concerns.


AUTHORIZATION TO RELEASE AND ASSIGN BENEFITS AND ACCEPT FINANCIAL RESPONSIBILITY

 


All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage. It is also customary to pay for services when rendered unless other arrangements have been made in advance with business office.


I request that payment of authorized Medicare/Other insurance company benefits be made either to me or on my behalf to Kathy L. P. Cook, M.D. for any services furnished me by that party who accepts assignment/clinician Regulations pertaining to Medicare assignment of benefits apply.

I authorize any holder of medical information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or carriers any information needed for this or a related Medicare claim/other Insurance Company claim. I permit a copy of this authorization to be used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. I understand it is mandatory to notify the health care provider of any other party who may be responsible for paying for my treatment. (Section 1128B of the Social Security Act and 31 U.S.C. 3801-3812 provides penalties for withholding this information).

   
Signature Date