ELIGIBILITY: Please be aware that your health insurance policy is a contract between you and your insurance company. It is an agreement that your insurance will pay for covered medical services as long as your premiums are paid. Because they may not pay for every service, you will be responsible for any non-covered charges. We will verify your eligibility before your visit but please keep in mind that a determination of benefits with your carrier is NOT a guarantee of payment.
DEDUCTIBLES: Before your visit, we will verify your deductible and/or co-pay amounts. If your annual deductible for
the calendar year has not been met, you will be responsible for any charges incurred during your visit, payable at the
time of service. We will also collect any co-pay amounts at the time of service.
OUTSIDE SERVICES: Please be aware that your care may require the use of laboratory or pathology evaluation. These studies are not performed at our practice so please understand that you will receive a separate bill from the pathologist or laboratory providing those services. If you have a preference for a specific facility, please notify us prior to any procedure so that we can do our best to accommodate you.
I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for the services provided. I also authorize El Segundo Dermatology or my insurance company to release any information required to process my claim.