Thank you for choosing SkinMD as your health care provider. We are committed to providing the highest quality of patient care. We have prepared this Statement of Financial Responsibility for your information. Please read and sign this form, prior to receiving treatment.
I acknowledge and agree that I am responsible for and will pay for all regular charges for items, services and treatments provided to me by SkinMD, including any amount not paid by my insurance plan. I understand that I can request additional information about charges or may obtain an estimate prior to or after signing this agreement.
I understand that some items or services that SkinMD may provide to me may not be covered by my insurance carrier, and I agree to be personally responsible for any such non-covered items or services more than the limits in my member benefit agreement.
I understand that I am personally responsible for any non-covered items or services that are listed on the financial responsibility for non-covered items or services form. I understand that I am personally responsible for deductibles, co-pays and co-insurance established by my member benefit agreement.
I hereby agree that if SkinMD has agreed to bill my insurance or other third-party carrier, it has agreed to do so as a courtesy, and that SkinMD has the right, should SkinMD deem it advisable, to demand payment from me at any time prior to full payment from any insurance or third-party carrier, unless SkinMD and my insurance company or third-party carrier have agreed that I will not be billed.
I understand and agree that I have been advised that I may be billed by SkinMD and that this Assignment of Benefits and Agreement to Pay applies to all Skin MD services. If my account becomes delinquent and is referred for collection, I agree to pay the reasonable attorney’s fees, court costs and /or collection agency fees associated with the collection process.
I hereby authorize and request all insurance carriers with whom I have coverage to pay directly to SkinMD any and all benefits due under the terms of my policy for items or services provided by SkinMD. If my health insurance will not allow direct payment to SkinMD, I agree to immediately forward to SkinMD all health insurance payments I receive for my care at SkinMD.
By signing in the space below as Patient/Legal Representative or Guarantor, I hereby agree that all charges connected with this treatment or any other treatment rendered to the patient past or future, not covered by any insurance program are due and payable at time of service.
Patient Name/Signature (type):
I authorize SkinMD to bill to my credit card any amount due for any deductible, co-payment or coinsurance as determined by the insurance carrier for the patient named above. (Optional)
Credit Card #:
Name as it appears on Card:
Type of Credit Card