Billing Policies Apr 23, 2020 Order Number BILLING POLICIES PLEASE INITIAL EACH LINE Initials * Senter Dermatology cannot accept new patients on Medicare or Medicaid, we are not an authorized Tricare provider, nor do we participate in Workman’s Compensation claims. SENTER DERMATOLOGY CANNOT BILL AND IS NOT CONTRACTED WITH MEDICAID, TRICARE, VA, CHAMPUS, OR DENALI KIDCARE. Initials * Senter Dermatology cannot bill insurance nor seek prior-authorizations for preventive health care services and most cosmetic services. Initials * I agree to pay my office co-pay amount (if applicable) and 20% of any remaining amount owed at the time of my visit. I have been given the opportunity to pay my estimated deductible and coinsurance at the time of service. I authorize my insurance company to pay my benefits directly to Senter Dermatology and I understand that I will be fully responsible for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional charges over and above the insurance payment. I have chosen to assign benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the prompt payment of the claim by my insurance company. Initials * I am aware that I am responsible for any balance from any procedures/treatments that have been denied (especially that involve Botox® or lasers), REGARDLESS if my insurance company has stated that they approve said procedures/treatments. Initials * I am aware that if more than three appointments are missed, or if I fail to contact Senter Dermatology in a timely fashion to cancel or reschedule an appointment, the provider may decide to discontinue care. Initials * I am aware that it is my responsibility to respond to mailed or phone requests for follow up. Failure to respond in a timely manner to mailed or phone messages regarding my follow up may result in my discharge from Senter Dermatology. Initials * I am aware that I am responsible for providing accurate and complete insurance information. I am aware that it is my responsibility to contact the insurance company if a claim is thirty days or more past due, to pay all outstanding balances after sixty days, regardless of whether or not the insurance has made a determination on the claim. I am also aware that it is my responsibility to promptly pay any balance remaining after the insurance finalizes the claim and to promptly respond to any questionnaires or updates sent out by the insurance company regarding coverage so as not to delay claim payment. If I fail to supply an insurance company with requested information, the account will be turned over to a collection agency immediately. If I cannot provide my insurance card at the time of visit, I will pay IN FULL and will be given the proper paperwork to submit to insurance myself. Initials * I authorize, Senter Dermatology, to release any information necessary to adjudicate the claim, and understand that there may be associated costs for providing information beyond what is necessary for the adjudication of a clean claim. Initials * I also understand that should my insurance company send payment to me directly, I will forward the payment to Senter Dermatology within 72 hours. I agree that if I fail to send the payment to Senter Dermatology and they are forced to proceed with the collections process; I will be responsible for any cost incurred by the office to retrieve their monies. Any violations of this agreement will, at the provider’s election, terminate patient charge privileges with Senter Dermatology and bring any balance owed by me, the patient, to Senter Dermatology to be due and payable immediately. Initials * I authorize, Senter Dermatology, to initiate a complaint or file an appeal to the insurance commissioner or any payer authority for any reason on my behalf, and I personally will be active in the resolution of claims delay or unjustified reductions or denials. Initials * I understand that all services rendered to me by the providers at Senter Dermatology are my financial responsibility, and that the provider will bill my insurance company as a courtesy. First Name * Last Name * Email Address * Today's Date * INSURANCE INFORMATION If you do not have the following information readily available at the time of your visit you will be asked to pay your visit in full. Please present card to front desk. We only submit to a maximum of two insurances. Proper paperwork can be given to you to submit to any remaining insurances yourself. PRIMARY INSURANCE Insurance Company Name * Insurance Phone Insurance Company Address Address * City * State * - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Insurance Identification Number With Prefix * Insurance Group Number * Subscriber Name * Subscriber Date of Birth * Subscriber Address Address * City * State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Subscriber SSN Subscriber Contact Number * Subscriber’s Relationship to the Patient * Self Spouse Parent/Guardian Other If Other, What Relationship To Patient SECONDARY INSURANCE Insurance Company Name Insurance Phone Insurance Company Address Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Insurance Identification Number Insurance Group Number Subscriber Name Subscriber Date of Birth Subscriber Address Address City State - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code Subscriber SSN Subscriber Contact Number Subscriber’s Relationship to the Patient Self Spouse Parent/Guardian Other If Other, What Relationship To Patient I attest that the above information is accurate and I understand Senter Dermatology’s office policies.
