GUARANTOR / PERSON RESPONSIBLE FOR BILL

Please give your insurance card to the receptionist upon visit.

PRIMARY INSURANCE INFORMATION

SECONDARY INSURANCE INFORMATION (If Applicable)

By checking below, I authorize the release of medical information to my primary care or referring physicians if needed and as necessary to process insurance claims, insurance applications and prescriptions whether by mail or by fax. I hereby release and discharge Southeastern Dermatology from all liability in connection with such release of information. I also authorize payment of medical benefits to the physician. I also understand that regardless of any insurance coverage I may have, I am responsible for any bills incurred and will be responsible for any charges associated with collecting this debt.
While we will assist with billing your insurance company, you are primarily responsible for determining what your insurance will cover, whether you require a referral, and/or the payment of your bill.

Thank you for choosing us as your health care provider. We are committed to your treatment being successful and your health is our greatest concern. The following is a statement of our Financial Policy, which we require that you read and sign prior to any treatment so that you understand your responsibility regarding the charges for services rendered by this office.

All patients must complete and sign our Registration Form in full before seeing the physician. If you have insurance which will pay our physician directly, and which we can verify, we still require that all co-payments, deductibles, co-insurances and charges for non-covered/cosmetic services be paid for at the time service is rendered. We will file both your primary and secondary insurance. If you have Medicare as well as a secondary coverage that is not a Medigap, we will file a claim to your secondary carrier.

If you are a member of an HMO or PPO which requires a referral form from your primary care physician, you are responsible for having the referral in our office prior to your appointment. Payment is due at the time of service. We accept cash, checks and credit cards. If needed, a payment plan can be established with prior approval from the practice manager.

If you are unable to keep your appointment, kindly give a 24-hour notice. Please help us to serve you better by keeping scheduled appointments. If you are more than 15 (fifteen) minutes late for your appointment, you may asked to reschedule for another date.

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

I authorize Southeastern Dermatology Consultants, PC and its employees the following:

(Please check Yes or No)