Financial Policy Form

Financial Consent Form

In order to establish optimal relations with our patients and avoid misunderstandings, our staff is trained to consistently inform you of our financial payment policies. Payment is required for all services at the time they are rendered unless you are insured with a plan in which we participate. Our staff will make a good faith effort to pre-verify your coverage. For those insured patients, applicable co-payments, co-insurance and/or deductibles will be collected at the time of service. We accept payment in the form of credit card only. If you have medical insurance, we will help you to understand your benefits. However, it is your responsibility to understand the benefits your insurance has for you. All self pay patients (which include those patients receiving cosmetic services) are required to pay in full at the time of service. For cosmetic appointments, a $50 deposit is required at the time of scheduling the appointment. This deposit is non-refundable in the case of a no show. If a biopsy or other surgical procedure is performed specimens are sent for processing and/or analysis to an outside laboratory. This may result in a separate bill and a charge to your account. Likewise any other blood or laboratory test done outside the premises of Reisenauer Dermatology may also result in a separate bill and a charge to your account. In the event that your account must be turned over to a collection agency, a 30% collection fee as well as a $30 returned check fee (when applicable) will be added to your account balance.

Cancellation Policy

Our office strives to provide you with exceptional medical care provided in a warm, professional environment. In order to ensure timely scheduling for all patients, we request 24 hours notice to cancel an appointment. If you fail to show up for an appointment without notice, we will not charge you the first time. However, if this occurs more than once you will be responsible for a cancellation fee of $50. If you fail to show up for a third appointment, we will require a $50 deposit to schedule a subsequent appointment. For surgery appointments, 48 hours notice is required to cancel an appointment.

Your signature below signifies your understanding and willingness to comply with these policies.