Wichita Dermatology & Aesthetics Review Our Patient Financial Policy

Carefully review the following information and ask if you have any questions about our fees, policies and/or your responsibilities.

We request all patients complete our Patient Information Form and Medical History Form prior to seeing the provider. Please notify our office of any patient information changes (i.e., address, name, insurance information, etc.).

We accept cash, checks, MasterCard, Visa, Discover or Care Credit. Your bill may include office visits, in-office procedures, pathology, laboratory, or other charges. You may also receive bills from outside pathology and laboratory clinics that we utilize, as well as other physicians and/or surgery centers, if your procedure is not performed in our clinic. Amounts not covered by your insurance are your responsibility. Co-payments must be paid at the time of service, or your appointment may be rescheduled. Failure to pay your account balances could result in your account being placed with a collection agency.

Insurance

It is the patient’s responsibility to provide our clinic with current insurance information. Our relationship is with YOU, not your insurance company. Kansas’ law states that clean insurance claims should be paid within 30 days from receipt (K.S.A. 40-2442). Please call your insurance company if your bill is not paid promptly. Please check with your insurance company to verify our providers participate with your network. We do not accept workers’ compensation claims or state insurance.

Deductibles/Co-Insurance

For certain procedures, our office may require the collection of your deductible and/or co-insurance prior to scheduling.

Pathology/Laboratory Services

Some services, such as blood work, tissue obtained from biopsies, etc., require an outside laboratory for processing and evaluation. Billing for these services will be directly handled by these outside providers, who may or may not participate with your insurance plan. If your insurance plan requires the use of a specific lab, it is your responsibility to notify our staff.

Referrals/Preauthorizations

If you have an insurance plan that requires you to have a referral to be seen in our office, it is your responsibility to obtain a referral from your primary care physician and ensure our office has a current copy. If our office does not have a current referral on file, you will need to sign a self-referral form at the time of your appointment stating that you will be responsible for payment in full for that day’s services. If you do not wish to sign a self-referral, you may be asked to reschedule your appointment until you can obtain a referral. If your insurance company requires a preauthorization for a procedure, it is your responsibility to ensure our office has the preauthorization prior to having the procedure performed.

Self Pay Patients

New patients who do not have insurance will be required to pay a $50 deposit at the time of scheduling. This deposit will be applied towards services received. In the event the patient no longer desires to be seen in our office, the deposit will be refunded provided 24 hours notice is given. Self-pay patients will be offered a 15 percent discount for services performed in our office, provided they pay in full at the time of service. Surgery patients who do not have insurance must make payment/payment arrangements prior to surgery. Payment is expected when services are provided.

Credit Card On File

We may require a credit card be kept on file for certain account types. Examples include accounts on payment plans, those previously turned to collection, self pay patients, etc.

Disputes

We will not become involved in disputes between you and your insurance company regarding coverage and/or policy benefit criteria (i.e., deductibles, non-covered services, co-insurance, etc.) other than to supply factual information when necessary for insurance plans with which we participate.

Bad Debt/Collection Balances

Any balances classified as bad debt or collection must be satisfied prior to being seen in our office, with the exception of a true medical emergency. Multiple collection events could result in your discharge from our practice.

Minors

The parent/guardian that signs this Patient Acknowledgement on the Patient Information Sheet will receive the billing statements for the minor and will be responsible for payment on the minor’s account.

Miscellaneous Fees

Collection Fees

All account balances sent to an outside collection agency will be assessed a 25 percent collection fee.

Missed Appointments

If you fail to cancel your surgery (including excisions, Mohs and TCA peels) appointment prior to 24 hours of the time the surgery is scheduled, you may be subject to a $100.00 fee. If you fail to cancel your clinical appointments prior to 24 hours of the time your appointment is scheduled, you may be subject to a $50.00 fee.

Form Completion

There is a fee of $10.00 to complete skin cancer policy claims forms and disability claims forms. These fees must be paid before the service will be performed. Please allow seven to 10 days for the completion of any forms.

Medical Records 

Copies of your medical records can be obtained from our Patient Portal. Personal requests for records are subject to copying fees.

Multiple Statements

A fee of $5.00 will be billed for each additional statement over two statements sent.

Returned Checks

There is a $25.00 fee for any check returned for insufficient funds.

Payment Plans

All accounts over 120 days, including payment plan accounts, will be assessed 18 percent interest annually.

Refunds

Patient refunds of $20.00 or greater will be automatically processed and mailed to the address on file. Refunds less than $20.00 will remain as credits on the patient’s account unless a refund is requested by the patient.

Insurance Information Release Authorization

I hereby authorize the above physician to release any information acquired in the course of my examination or treatment to my referring doctor and/or my insurance company.

 

This policy is subject to change without notice.

Revised 06/25/2021