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Patient Financial Policy

Mountain West Dermatology

Patient Financial Policy

The following information outlines the patient financial policy of Mountain West Dermatology.

Cancellation and No Shows – Please be courteous and provide at least 24 hours’ notice when you need to cancel an appointment. If you do not cancel and fail to come to your appointment (“no show”), you will be charged a $25 “no show” fee. This fee must be paid before additional appointments can be scheduled.

Initial – I understand the cancellation and no show policy.

Self Pay/Services not billed to insurance – All patients who do not carry health insurance or who choose not to have services billed to their insurance company are required to pay 100% of office visit charges at the time of service. We accept cash, personal checks, credit and debit cards. Additional charges incurred during the visit with the provider, such as a procedure or laboratory services, may be balance billed. We offer a 10% discount to all charges paid in full at time of service.

Insurance – Expenses incurred in our clinic are submitted to your insurance carrier as a courtesy. It is the responsibility of the patient and/or the responsible party to understand their insurance policy. Insurance copays should be paid at the time of service. After your insurance has determined benefits, any coinsurance amounts or non-covered services are the responsibility of the patient or responsible party. We will submit claims for primary and secondary insurance.

Medicaid – All Medicaid recipients must present their Medicaid card at time of service. Any Medicaid recipient who participates in the Healthy Connections program must have a referral from their Healthy Connections provider.

Outside Services – Patients will receive separate statements for laboratory and pathology services.
Laboratory services provided by Express Lab.
Pathology services provided by Pinkus Dermatology of Michigan and Pathology Associates of Idaho Falls.
Any billing questions should be directed to the correct service provider.

Outstanding Balance and Past Due accounts – Patients who do not pay the balance due in full are subject to the following payment guidelines:
After a claim has been processed by insurance, patients will have a 90 day grace period to pay their account without penalty or finance charges.
Finance charges begin accruing on all unpaid balances at 90 days past due. The finance charge annual percentage rate (APR) is 18%, with a minimum finance charge of $5.00.
For all account balances older than 90 days, patients are REQUIRED to participate in AutoPay, our automated payment program, with either a credit or debit card.
After the 90 day grace period, if a patient account is not paid in full AND the patient does not participate in AutoPay, the account will be sent to our collection agency, Medical Recovery Services (MRS). Payment arrangements can be made with them. A collection fee (33% of the balance due) will be added to the account.

I have read and agree to the above outlined financial policy of Mountain West Dermatology. I agree that I am ultimately responsible for any charges incurred at Mountain West Dermatology.

Patient Name: __________________________________ Date of Birth: ______________
Patient/Responsible Party: Printed Name: __________________________________
Signature: __________________________________ Date: ______________