Office Financial Policy

PAYMENT AT TIME OF SERVICE: Payment is due in full at the time of service unless you are covered by Medicare or an insurance company with which we participate. Methods of payment accepted are Cash, Visa, Mastercard, American Express, CareCredit, and Discover.

INSURANCE: Patients will be asked to present their insurance card to the receptionist for copying upon check-in at the office each time they are seen for medical services. Please make it a point to bring your insurance card with you each time that you visit our office. It is the responsibility of the patient to provide accurate insurance and personal information including any preferred laboratory cards. If your insurance requires a referral, it is your responsibility to provide the referral prior to your visit. You will be responsible at the time of service for the payment of copays, unpaid deductibles, and past-due balances.

For those patients covered by insurance plans with which we ARE participating providers, all co-payments, deductibles and noncovered services are due at the time of service. We will file the insurance claim to the insurance company. In the event that your insurance coverage changes to a plan with which we ARE NOT participating providers, we will require payment in full at the time of service and we will file your claim to the insurance company as a courtesy. Any charges that are not paid by your insurance company are your responsibility. Your insurance policy is a contract between YOU and your insurance company. Any pre-certifications of procedures or testing are your responsibility. Please let us know in advance if your insurance company requires this.

SELF-PAY AND COSMETIC: Payment is expected in full at the time of services - no refunds are allowed for performed services under any circumstance. Cosmetic and Medical Products: There are no returns accepted on any of our skincare products.

PATHOLOGY: is ordered by physicians to properly diagnose certain skin disorders. To increase the quality of care for our patients, we utilize a licensed lab separate from Chicago Skin Clinic. The analysis of these specimens is then performed by independent board-certified Dermatopathologists who specialize in this microscopic diagnosis of skin disorders. Charges for these services are IN ADDITION to your office visit charge and procedure charge. Please note that you may receive a separate bill for pathology services which will be billed to your insurance.

COLLECTIONS: Please note, if payment is not received from either you or your insurance company within 60 days from the date of service(s), your account will be considered delinquent and subject to referral to an outside collection agency.

CANCELLATIONS and MISSED APPOINTMENTS: We understand that unexpected events, illnesses, etc occur. When this happens, call our office as soon as possible to inform us of such issues. In the case of missed appointments or cancellations within 24 hours of the appointment:

**Office Visit- I understand that it is my responsibility to cancel my appointment 24 hours in advance of my appointment time and date, otherwise a $35 fee will be billed to my account which is not covered by my insurance plan.

**Surgical/cosmetic procedure appointments- I understand it is my responsibility to cancel or change my appointment at least 24 hours prior to my appointment time and date, otherwise, a $200 fee will be charged to my account which is not covered by my insurance plan.

The authorization for the release of medical records will be provided to you upon request. A signed authorization is needed to release medical records and a new release is required every 12 months. Please allow 72 hours to process medical record requests after we have received your signed form. In some instances, there could be a fee required for the retrieval of your medical records. For FMLA forms, there is a $25 fee for completion of forms - this fee must be paid in full and is not covered by insurance.

Credit Card Authorization (Credit Card on File): I authorize Dr. Del Campo and Chicago Skin Clinic to charge my credit card above for agreed-upon purchases, procedures, missed appointments, or services. I understand that my information will be saved to file for future transactions on my account. My information will be stored in bank-level security using Square. This authorization will remain in effect until canceled.

Thank you for your understanding and cooperation as we strive to best serve the needs of all our patients.