Step 1 of 6

16%
  • AGREEMENT TO PAY

    In order to establish an optimal relationship and avoid misunderstandings and confusion regarding our payment policies, our staff is trained to inform you of the financial payment policies of this office. Payment is required at the time services are rendered unless you are covered by an insurance company with which Retief Skin Center participates. We accept payment in the form of cash, check, or credit card. I understand that it is my responsibility to present accurate, current insurance coverage information at time of check in. At that time, I will be asked to pay for all services not covered, deductible amounts, co-pays, past due balances, as well as balances due resulting from invalid insurance information. For patients wiih HMO coverage or other third party insurance that require authorizations, I will be held responsible for payment if this referral authorization is not provided at the time of service. I, as the patient or responsible party for the patient, agree to be responsible for charges or services referred to another physician or laboratory by any physician/practitioner of Retief Skin Center. I understand that failure to make payment when due is the basis for legal action, and agree to pay any and all cost of collection, including attorneys’ fees. I understand it is the policy of Retief Skin Center to collect any outstanding balance before additional services are rendered. I authorize and request that payment by an authorized insurance company be ma de payable to Retief Skin Center on my behalf for the services furnished to me by the physician(s)/practitioner(s) of Retief Skin Center This signature verifies the agreement to the above as the patient or the responsible party for the patient.
BrianHIPPA