Please remember that your health insurance is a contract between you, the patient, and your insurance company. It is YOUR responsibility to know your health plan benefits, including co-payment amounts, deductibles, co-insurance, required referrals, and lab contracts. As a service to you, we will submit a claim to your insurance company for all medical visit charges, but we do not share in the contract between you and your insurance company.

A copy of your photo ID, credit card, and insurance card (front and back) is required by our billing department to assist you in filing your claim. The credit card on file will be used after 30 days for any outstanding balances. You are responsible for any charges not covered by your insurance plan. It is the patient’s responsibility to inform this office if your insurance requires pre-certification or pre- authorization of services prior to scheduling of such services. The patient will be responsible for services denied by insurance due to “No Eligibility,” “Non-Covered Service,” or “Pre-authorization/Certification Not Obtained.” By signing this agreement, you understand that once your insurance plan has paid their portion of your care, you will receive an Explanation of Benefits (EOB) from your insurance company. Statements are released after our billing department receives any of the following: an insurance payment, an insurance denial, or an insurance non-payment for any reason. You are responsible for any charges not covered by your insurance plan.

Referrals: Your insurance may require a referral to be submitted by your primary care physician before seeing a specialist (dermatology is a medical specialty). It is your responsibility to obtain any necessary referrals for your insurance plan to accept a claim for the visit. If you don’t have a referral at your appointment time, your appointment will need to be rescheduled. If a claim is denied due to lack of having this required referral, you (the patient) will be responsible for full payment of the office visit.

In-Network Coverage: For insurance companies that we are contracted with, we will estimate your out- of-pocket expenses due at the time of the visit. Copayments, co-insurance, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due at the time of service.

Medicare Patients: We will bill Medicare for you. We must have your signature on file and we will also bill secondary insurance carriers for you. All copayments are due at the time of service. The patient will be responsible for any balance not paid by Medicare and secondary insurance.

Out-of-Network Coverage: For these plans, your co-payment is due at the time of visit. You are responsible for the charges of the provided services, which may be higher than the similar services for an in-network provider. Co-payments, co-insurance, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due at the time of service. You may opt to be a Self-Pay patient and submit your bill for reimbursement to your insurance company.

Out-of-pocket expenses: Co-payments, co-insurance amounts, deductibles, and all non-covered items and charges are the insured/patient’s financial responsibility and are due at the time of service. Recent shifts in the healthcare industry have resulted in insurance companies increasingly transferring costs to the insured; you the patient.

Self-Pay Patients: Self-Pay or uninsured patients are responsible for payment at the time of service. The fee schedule is based on the established Medicare fee schedule in place. Self-Pay patients must keep a credit card on file.

Non-Covered Services: Cosmetic and aesthetician services cannot be submitted to insurance, and payment in full is due at the time of service by credit card, check, cash, or care credit.

Outstanding balances: Our billing department will send you a statement explaining your balance due. Payment is expected within 30 days of receipt of the statement. It is the patient’s responsibility to ensure an up-to-date address is on file. If payment is not received after receiving 3 statements for the same unpaid balance, the account will be transferred to a collection agency and will be flagged as delinquent in the office. This will impede your ability to schedule future non-essential appointments until all balances are paid in full. We will have the option to require a deposit for future scheduled appointments for those patients with a delinquent account history. Failure to pay balance due can result in dismissal from the practice.

Return Check Fee: All returned checks will be charged a $30 processing fee.

Pathology/Laboratory Services: Dermatology Center of the Rockies, PC. uses third parties for our laboratory work and pathology services. You/your insurance will receive an additional bill from the lab service provider Pathology Watch. We are unable to adjust these charges as they are coded and billed by a separate entity.

MOHS procedures: Patients will sign a secondary financial consent form specific for these procedures.

Missed & Canceled Appointments: We request that you provide at least one business day’s notice to cancel a medical appointment. We do this so your appointment slot can be offered to another patient in need of attention. You will be charged a $50 fee if you fail to keep your appointments or cancel/reschedule with less than 1 business day’s notice.

Surgery & Cosmetic appointments: Cosmetic patients must maintain a credit card on file. We require at least 1 business day’s notice to cancel or reschedule an appointment. If you fail to keep your surgery or cosmetic appointment, your credit card will be charged a $50 fee. For larger procedures, 50% of the estimated fee will be collected as a deposit at the time of scheduling, and this deposit will be forfeited if the appointment is canceled or rescheduled with less than 1 business day notification. After TWO missed appointments in a row or same-day cancellations, you may be dismissed from the practice.

Cosmetic Consultations: The cosmetic consultation fee is $100. The base cost of $100 will be reduced from the cost of any cosmetic procedure or treatment scheduled within 90 days of the consultation. A credit card on file is required and will be charged a cancellation fee of $100 if the consultation is rescheduled or canceled without 1 business day’s notification.

Cosmetic packages: We offer packages on several cosmetic treatments as a way of cost savings to our patients. The full cost of the package is to be paid in full at the first session. Packages are non-transferable to any other person. If a patient opts to terminate the package prior to completion, the treatments received will be charged the full cost per treatment (not the discounted package cost), and the patient will be refunded the remaining amount. Refunds can only be requested within 6 months of the first treatment. Packages must be completed within 12 months of purchase.

Prescription Policy: Please call for refills during regular office hours and leave the patient’s name, DOB, phone number, medication, and the pharmacy requested. Please allow 48 business hours to complete the request. Some prescriptions may be delayed due to completing a Prior Authorization form set forth by the insurance companies. For oral medications, biologics, and some topical medications, the patient needs to be evaluated every 6 months. We cannot refill a prescription if the patient has not been evaluated within 12 months.

board certified dermatologist. medical dermatology. cosmetic dermatology. botox. coolsculpting. fillers.

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