FINANCIAL POLICY AUTHORIZATION - Effective date March 16, 2020
• I understand that I must present valid evidence of insurance coverage along with valid government issued identification. ______Initial
• I grant permission to bill my insurance provider and authorize payment for services rendered to me to be paid directly to CCSD. ______Initial
• I understand CCSD will make an attempt to verify eligibility and benefits prior to my visit. In doing so, CCSD will collect any estimated out of
pocket expenses, such as; services that may be applied towards my deductible, subject to copayment or coinsurance, in which case will be
my financial responsibility and collected at the time of service. ______Initial
Disclaimer: CCSD cannot guarantee the verification of eligibility and benefits or expected payment conveyed to us or to you by your insurance
provider will be accurate or complete. Benefits and payment are subject to all terms, conditions, and exclusions of the member’s contract at
the time of service. We strongly suggest you have an understanding of your insurance benefits and monitor your account with our office.
• I understand if my insurance provider delays or withholds payment, for 90 days or longer, the balance due will become my financial
responsibility. ______Initial
• I understand if I fail to: obtain a referral (if required), pay my insurance premium, or coordinate my benefits, I will be financially responsible
for my services. ______Initial
• I understand I may incur separate billing charges for pathology and/or laboratory services from our office or the facilities we utilize.
______Initial
• I understand Self-Pay patients, or patients seeking care outside of utilizing their insurance benefits, are expected to make payment in full at
the time of service. ______Initial
• I understand that if I am unable to keep an appointment, I must provide the minimum of a 24-hour business day notice otherwise the
following fee will apply: $25 for general dermatology appointments, $50 for any cosmetic or aesthetics appointments, $100 for surgical
procedure appointments. In addition, any required deposits taken for procedures or Saturday appointments will be forfeited if appropriate
notice is not received. All quoted cosmetic procedures will be subject to the terms, conditions and cancellation policy fee of that quote.
______Initial
Our facility will require that you maintain a valid credit card in our PCI compliant secure database for all services that are billed to your insurance
carrier. CHECK ONLY ONE OPTION:
Credit Card Option:
I wish to secure a credit card and authorize Chicago Cosmetic Surgery & Dermatology and Chicago Skin Science to charge any balances due on my
account.
Please check if you would like to be notified prior to the processing of your card.
No Credit Card Option:
I decline to secure a credit card and will pay my balance at the time of service.
Statement Option: (MEDICARE ONLY)
I will receive a statement from Chicago Cosmetic Surgery & Dermatology and remit payment within 30 days of its receipt.
Credit Card Information:
Name of Cardholder: ___________________________________ __________________________________
Last Name First Name
Card Type: □ Visa □ MasterCard □ American Express □ Discover CHECK IF HSA □ *HSA cards require an additional card to be secured.
Credit Card Number: XXXX – XXXX – XXXX -_____ _____ _____ _____ Expiration Date: _______ /_______
Authorized Signature: ____________________________________________ Date: ___________________
Name of Cardholder: ___________________________________ __________________________________
Last Name First Name
Card Type: □ Visa □ MasterCard □ American Express □ Discover
Credit Card Number: XXXX – XXXX – XXXX - _____ _____ _____ _____ Expiration Date: _______ /_______
Authorized Signature: ____________________________________________ Date: ___________________
I hereby acknowledge receipt of goods and services, and authorize Chicago Cosmetic Surgery & Dermatology and Chicago Skin Science to bill the
credit card I have provided above to keep on file for such. I agree to take all further actions required to pay the charges in full and to perform the
obligations set forth in my agreement with my credit card issuer. I understand any unpaid balance on my account considered past due is subject to
be turned over to a collection agency. I have read, understand and agree to this policy. (Parent or Guardian complete if patient is a minor)
_____________________________________ ______________________________________ ________________
Print Name Signature Date
