Thank you for choosing Brinton Lake Dermatology for your skin health needs. We are committed to providing you with exceptional care, as well as making our insurance billing processes as simple and efficient as possible. With the changing environment in healthcare, more responsibility of payment is being placed on the patient in the form of copays and deductibles. Thus, it has become necessary to ensure we have a guarantee of payment on file in our office.

Effective Monday, March 2, 2021, Brinton Lake Dermatology will require all patients to keep an active credit card on file with us. We will bill your insurance company first and upon their determination of benefits, we will send you a bill. If that bill is not paid by the last day of the month, we will charge the amount due to your credit card. Circumstances when your card would be charged include but are not limited to:

• missed or canceled appointments without 24-hour notice
• missed copayments, deductible and co-insurance
• any non-covered services and/or denial of services allocated to patient responsibility
• any amount not paid by your insurance

This in no way will compromise your ability to dispute a charge or question your insurance company’s determination of payment.

By entering your credit card information, you agree to keep an encrypted copy of your credit card on file with Brinton Lake Dermatology and authorize us to use that credit card information to pay any balance due in excess of 30 days.

Payment Policy

Payment of all co-pays is due at check-in before your appointment. As a service to you, our office will bill your insurance company. Most insurance companies require that we collect these fees, as they are terms of your health care contract. Additionally, patients are ultimately responsible for all balances. Due to the constant changes in health insurance, it is your responsibility to know your health coverage. If you should have any questions regarding if a certain procedure is covered, it is to your advantage to call your insurance company and find out exactly what your contract covers. Their customer service representatives will be happy to assist you. Our mission is to provide you with the highest quality dermatological care possible. With this in mind, we are constantly trying to control our costs while conforming to the standard fee schedules approved by most major insurance companies. Our receptionist will need to verify your insurance coverage prior to your visit.

1. Your medical insurance card and personal identification must be presented to the receptionist at each visit.

2. Any outstanding balances should be paid before your office visit or procedure unless prior payment arrangements have been made.

3. Your insurance is a contract between you and the insurance company. While we accept the reimbursement rates of many insurance companies, we are not a party to your contract and therefore do not determine which medically necessary services they cover and which they do not.

4. Our relationship and treatment responsibility is with/to you. We will attempt to notify you whenever we know a test or service is not covered. There will, however, be times when we cannot determine this. Whether covered or not, you are ultimately responsible for payment of the services received.

5. We require payment in full on the date of service for co-pay and offices charges defined under your policy as your responsibility.

6. A $15 administrative fee for delayed payment will be added to your balance if you choose not to pay at the time services are rendered. This $15 fee is not billable to your insurance company; it is your responsibility. To avoid this fee, you must pay at the time of service.

We realize that, on occasion, temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us promptly for assistance.

Appointment Cancellation Policy Agreement

Brinton Lake Dermatology is committed to providing all of our patients with exceptional care. Each time a patient misses an appointment or cancels without giving enough notice, they prevent another patient from being seen.

Please call us at 484-785-3376 by no later than 12:00 Noon on the day prior to your scheduled appointment to notify us of any changes or cancellations. TO CANCEL A MONDAY APPOINTMENT, PLEASE CALL OUR OFFICE BEFORE 12:00 NOON on FRIDAY.

If prior notification is not given, Brinton Lake Dermatology reserves the right to charge a fee of $60.00 for all missed office appointments (“no shows”) and appointments which, absent a compelling reason, are not canceled within the time frame noted above. For any 30 minute or more surgical or cosmetic appointment not canceled within the time frame above, there will be a fee of $100 to $150. This fee is not covered by insurance, and must be paid prior to your next appointment. Multiple “no shows” may result in termination from our practice. Thank you for your understanding and cooperation as we strive to best serve the needs of all of our patients.