Policies & Consents
PATIENT RESPONSIBILITY FOR PAYMENT
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Basic Policy:
Payment for service is due in full at the time the services are provided. For patients with insurance: Co payments are due at the time of service.
Missed Appointments:
I understand that if my appointment is cancelled without a 24 hour notice or if it is deemed a no show I will be charged a $50.00 fee. For surgeries, we require 72 hours notice to cancel/reschedule and a $100.00 fee will be charged for all no shows/late cancellations. I also understand that repeated occurrences may result in release from this practice.
Returned Check Policy:
There will be a $40.00 fee for a check returned by the bank for any reason.
Account Payments:
I understand that any balance due that is not paid within 60 days may be turned over to a collection agency and may increase for any recovery fees incurred by this process.
Authorization and Release:
I request that payment of authorized insurance benefits be made on my behalf to Hawaiian Islands Dermatology, LLC for any services rendered to me. I hereby agree to pay any and all charges that are not covered by insurance. I authorize the release of my medical information to my insurance company or Worker’s Compensation carrier that is necessary to determine benefits or the benefits payable for related services.
Privacy Practices Acknowledgment:
I have received and reviewed the private practices.