We are committed to providing you with the best possible care. In order to achieve these goals, we need to ensure your understanding of our payment policy.
Payment for cosmetic and private pay services is due at the time those services are rendered. We accept cash, checks (for established patients only), American Express, MasterCard, Visa and Discover.
All co-pays, deductibles and coinsurance amounts as verified with your insurance plan are due at the time of service and cannot be waived. All patient balances determined to be your responsibility by your insurance company will be automatically charged to the credit card provided by you in our EASY PAY program.
I understand if I have an unpaid balance to Resnik Skin Institute and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. All balances over 60 days are automatically referred to a collection agency. A $35 collection fee and all legally applicable interest will be added to the total owed. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts.
In order for Resnik Skin Institute or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Resnik Skin Institute and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable.
Claims for insurance companies with which we participate are submitted electronically by our billing company. We do not participate with Medicaid as primary or secondary coverage. Please notify the secretary before your appointment if you are a Medicaid patient.
If your check is returned unpaid, a charge of $35 for insufficient funds will be added to your account balance.
Missed appointments and appointments cancelled without 24 hours advance notice will incur a $50.00 charge.
By completing this form digitally and typing my name here, I acknowledge that this is my digital signature and understand it to be as legally binding as my cursive signature.