Statement of Patient Responsibilities

Patient Name: ______Date of Birth: ____/____/____

Financial Responsibility

River Region Dermatology and Laser appreciates the consideration you have shown in choosing our practice to provide for your healthcare needs. The services you have elected to participate in imply a financial responsibility on your part. The responsibility obligates you to ensure payment in full of our fees. I understand that I am financially responsible for charges not covered by this agreement; and for any charges that may occur do not want a claim submitted to my medical coverage carrier.As a courtesy, we will verify your coverage and bill your insurance carrier on your behalf. However, you are ultimately responsible for payment of your bill.

Co -Pay Policy

You are responsible for payment of any deductible and co-payment/ co- insurance as determined by your contract with your insurance carrier. We expect these payments at time of service. Many insurance companies have additional stipulations that may affect your coverage. You are responsible for any amount not covered by your insurer. If your insurance carrier denies any part of your claim, or if you and your physician elect to continue past your approved period, you will be responsible for your balance in full.

I have read the above policy regarding my financial responsibilities to River Region Dermatology and Laser. I certify that the information is, to the best of my knowledge, accurate.

** All co-pays are due in full at time of appointment. **

Self -Pay Policy

I do not have health insurance and will be responsible for services rendered by River Region Dermatology and Laser. I agree to pay the practice the full and entire amount of the treatment given to the above-named patient at each visit.

Appointment Policy

To keep our appointments running smoothly and in a timely manner, we kindly request that you:

  • Arrive 15-20 minutes early for your initial visit;
  • Please call 24 hours in advance to cancel your appointment. Failure to do so will result in a $25 “No Show” fee. Please be aware that Monday appointments must be canceled by noon on the previous Friday; and
  • Please call to inform us any time that you will be late for an appointment. If you are running more than 15 minutes late, you may be asked to reschedule your appointment. We will always try to accommodate you as we run late sometimes.

Appointment times reflect the health issues provided to the receptionist at the time the appointment is made (i.e.; acne, mole check, surgical procedure, cosmetic consultation). Lengthy delays result from patients asking for additional time to address issues other than those originally scheduled. Please be considerate of those waiting.

Patient or Guardian Signature ______Date ____/____/_____