Welcome to our practice! We are pleased that you have chosen us to provide your care. We feel that it is important that our patients are informed of the financial policies of this practice. We encourage you to discuss any questions you may have regarding these policies.

If a referral is required, it is the patient's responsibility to obtain the referral from their primary care physician prior to the scheduled visit. If no referral is available, the appointment will need to be rescheduled or the patient can pay for the entire visit at the time of service.

We will bill your primary (and secondary) insurance plan(s) for all charges for services rendered. You will be responsible at the time of service for payment of co-payments and charges for non-covered or cosmetic services. You will also be responsible for your annual deductible. In the event that we are not aware of a charge that is not covered by your plan, you will be billed for the balance after we obtain a denial from your insurance carrier.

If you have insurance coverage with a carrier with which we do not have a contractual relationship, you will be responsible for payment in full at the time services are rendered.

For your convenience, Three Rivers Dermatology accepts cash, check, Visa, MasterCard, American Express and Discover.

Any account overdue by more than 90 days may be referred to a professional collections agency.

Treatment of Minors: We realize that many families are in a state of change. Divorced, separated, single parents and blended families are now common. In many of these families, the question of who is financially responsible for the child's care can be complicated. The policy in this office is that the parent who requests treatment for the minor is responsible for all fees incurred.

Disability Forms: Disability forms can be very time-consuming to research and complete. A charge of $5.00 for each form that is required to be completed will be payable at the time the form is presented for completion.

RETURNED CHECKS: If a check is returned to us for insufficient funds, we will contact you and request a cash payment for the amount of the check. Due to the additional handling and charges made to us by the bank, an added fee of $30 will also be due for each check returned to us.

I agree that I may have to pay for the services provided to me by Three Rivers Dermatology. Even though I may have insurance coverage, I have final responsibility for payment to the practice. I therefore agree to pay for all medical charges my insurance does not cover either at the time of service or as soon as I have received notice. If I do not pay for the services within the specified time frame, I understand that I will also be responsible for all costs incurred.