If you prefer to complete a paper copy of the form you may print a copy and bring it with you to your appointment:
Please remember that your heath insurance is a contract between you and your insurance company. It is YOUR responsibility to know your health plan benefits, including co-payment amounts, deductibles, co-insurance, and lab contracts. As a service to you, we will submit a claim to your insurance company for all visit charges, but we do not share in the contract between you and your insurance company. You are responsible for any charges not covered by your insurance plan.
Some diagnoses might be considered cosmetic or may not be covered by your insurance company. Payment in full for these cosmetic services will be required at the time of service. Services provided which your insurance company determines are not covered under your plan are your responsibility and will be billed to you.
Please contact your insurance company with any questions you may have regarding your benefits and coverage.
Cо-Payments, Deductibles & Co-Insurance
If your insurance plan includes a co-pay, it must be paid upon check-in on the day of service. Please remember that your heath insurance is a contract between you, your employer and your insurance carrier. Failure to collect a required co-payment can constitute insurance fraud. If you cannot pay your co-pay on your day of service we will ask that you reschedule your appointment.
If your plan carries a deductible which has not been met, you will be asked to pay a minimum of 50% of the visit charges at the time of service based on your insurance company’s rates. If your deductible has been met and your plan includes co-insurance, you will be asked to pay a percentage of your co-insurance at the time of service.
Some insurance plans require a prior authorization or a referral from a patient’s Primary Care Physician to see a Specialist. You can determine whether you need prior authorization or a referral by checking your insurance card, or by calling your insurance company using the telephone number on the back of the card. Contact your PCP (primary care physician) if a a prior authorization or referral is needed for your visit. If either a prior authorization or referral is required, it must be received by us prior to your first visit.
Canceled, Late or Missed Appointments
- Please call the office at 480.855.0085 if you know you are going to miss an appointment. This courtesy will allow another patient to be seen in your place.
- If you are scheduled for surgery or another procedure and you cancel or “no-show”, we may not be able to re-schedule another appointment for you in a timely manner.
- If you are on Accutane and miss a scheduled appointment, you may run out of medication before we can schedule another appointment for you.
- To cancel an appointment, please call at least 24 hours before your scheduled appointment. We reserve the right to assess a $25 fee to your account for failure to provide a minimum of 24 hours’ notice should you choose to cancel your scheduled appointment or if you fail to show up for your scheduled appointment with no cancellation notice given.
- To cancel a surgery or other lengthy procedure, please call at least 48 hours in advance. Your failure to provide 48 hours’ notice will result in a $100 charge to you due to the amount of scheduled time that has been reserved specifically for you.
- Being substantially late for your scheduled appointment constitutes failure to show up. If you arrive 10 minutes or more after your scheduled appointment time, we may ask that you re-schedule your appointment.
- We accept cash, personal check, Visa, Master Card, Discover, American Express and Alphaeon Credit.
- Cosmetic and elective procedures require full payment on the day of service.
- Some diagnoses might be considered cosmetic or may not be covered by your insurance company. Payment in full for these cosmetic services will be required at the time of service. Services provided which your insurance company determines are not covered under your plan are your responsibility and will be billed to you. If you have any questions regarding your benefits and coverage, please contact your insurance company.
- If you need to speak to our billing department, please email: email@example.com or give our office a call at 480-855-0085 ext 3.
If there is a question of financial responsibility, the parent or legal guardian who accompanies a minor patient to the office visit will be responsible for the account.
Children and young adults under age 18 will need to be accompanied by a parent or legal guardian on their first visit. Our providers are not able to see children without a parent or legal guardian present. Once the initial visit has been completed, young adults of driving age can be seen without parent or legal guardian if we obtain a signed permission form. Permission form can be completed electronically through your patient portal or printed off to complete at home and bring in with you.
Patients without health insurance are welcome at Desert Sky Dermatology. Full payment for services is expected at the time of service.
Patients must bring written authorization with their claim number, company name and mailing address – plus the adjuster’s name, mailing address and telephone number.