OUR FINANCIAL POLICY
Thank you for choosing us as your health care provider. We are committed to your treatment being
successful and your health is our greatest concern. The following is a statement of our Financial Policy,
which we require that you read and sign prior to any treatment so that you understand your responsibility
regarding the charges for services rendered by this office.
All patients must complete and sign our Registration Form in full before seeing the physician.
If you have insurance which will pay our physician directly, and which we can verify, we still require that
all co-payments, deductibles, co-insurances and charges for non-covered/cosmetic services be paid for at
the time service is rendered. We will file both your primary and secondary insurance. If you have
Medicare as well as a secondary coverage that is not a Medigap, we will file a claim to your secondary
carrier.
If you are a member of an HMO or PPO which requires a referral form from your primary care physician,
you are responsible for having the referral in our office prior to your appointment.
Payment is due at the time of service. We accept cash, checks and credit cards. If needed, a payment
plan can be established with prior approval from the practice manager.
If you are unable to keep your appointment, kindly give a 24-hour notice. Please help us to serve you
better by keeping scheduled appointments.
If you are more than 15 (fifteen) minutes late for your appointment, you may asked to reschedule for
another date.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or
concerns.
I have read the Financial Policy and understand that I am responsible for all charges incurred by me. I
agree to pay any monies due to Southeastern Dermatology Consultants, P.C.
successful and your health is our greatest concern. The following is a statement of our Financial Policy,
which we require that you read and sign prior to any treatment so that you understand your responsibility
regarding the charges for services rendered by this office.
All patients must complete and sign our Registration Form in full before seeing the physician.
If you have insurance which will pay our physician directly, and which we can verify, we still require that
all co-payments, deductibles, co-insurances and charges for non-covered/cosmetic services be paid for at
the time service is rendered. We will file both your primary and secondary insurance. If you have
Medicare as well as a secondary coverage that is not a Medigap, we will file a claim to your secondary
carrier.
If you are a member of an HMO or PPO which requires a referral form from your primary care physician,
you are responsible for having the referral in our office prior to your appointment.
Payment is due at the time of service. We accept cash, checks and credit cards. If needed, a payment
plan can be established with prior approval from the practice manager.
If you are unable to keep your appointment, kindly give a 24-hour notice. Please help us to serve you
better by keeping scheduled appointments.
If you are more than 15 (fifteen) minutes late for your appointment, you may asked to reschedule for
another date.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or
concerns.
I have read the Financial Policy and understand that I am responsible for all charges incurred by me. I
agree to pay any monies due to Southeastern Dermatology Consultants, P.C.
(865) 474-8800