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Financial and Office Policies of Elisabeth G. Richard, MD, PA - Consent
Updated and effective January 1, 2025
Overview:
Payment is required for all services at the time they are rendered. If we accept your insurance, applicable co-pays, co-insurances, balances and/or deductibles will be collected at the time of service. Payment is also required in full at time of service for all cosmetic and/or non-covered services. You will be financially responsible for all charges due at the time of service if the Practice (Elisabeth G. Richard, MD, PA) does not participate with your health insurance and/or if you do not have health insurance coverage for a service. The Practice does not participate with any Medical Assistance (i.e Medicaid) programs. The Practice will only submit claims to you primary and secondary insurance, but not to any tertiary or additional coverage plans.
A copy of your insurance card and photo ID must be provided to file your claim and confirm your identity. It is the patient’s responsibility to inform the Practice of any insurance changes at the time the new plan is effective. If updated insurance information is not provided in a timely fashion, you may be financially responsible for services rendered if they are declined by your insurance carrier. Likewise, it is the patient’s responsibility to inform the Practice of any address and/or phone number changes. The patient is financially responsible for any and all services rendered not covered by the insurance plan.
Credit Card on File:
Our current financial policy requires that you keep a valid credit card (credit/debit/HSA) on file with the office. If a balance remains on your account three weeks after a statement is sent to you, the Practice reserves the right to charge the outstanding balance due to your credit card on file. Charges to the credit card on file are to be entered only for fees and balances due that are not covered by insurance. Please keep in mind, we will not charge your card if you do not owe anything.
This office takes the security of patient information very seriously. The credit card information on file will be stored in a secure manner and will not be shared with any third parties. With my signature below, I hereby authorize the Practice to retain my credit card information in a secured manner. After my insurance carrier has paid their portion of medical claims to the Practice as assigned benefits, I hereby authorize the Practice to charge this credit card for any outstanding deductibles, co-insurances, co-pays, unpaid fees and/or balances for services rendered to/for the person listed below. Charges to this credit card will not exceed $500 for any individual overdue balance. To capture and store the card in the PCI compliant encrypted platform, a test charge of $0.01 may be processed and the $0.01 will be refunded to that same card the same day. This authorization will remain in effect until revoked by me in writing.
A copy of the credit card receipt and an account statement will be sent to the patient/guarantor if the credit card is charged. If you dispute the charge with the bank/credit card company, we reserve the right to dismiss you from the Practice. This in no way compromises your ability to question your insurance company's determination of payment.
Referrals and Insurance:
If your insurance plan requires a referral from your primary care physician prior to your visit, it is your responsibility to bring the referral. If you do not have the referral at the time of your visit, you will be required to pay the full office charges.
Your insurance is a contract between you, your employer & the insurance carrier. We do not have all the details of your specific plan. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. If the Practice is out-of-network with your insurance, you are financially responsible for services rendered, and charges may be higher than with an in-network practice. If your insurance changes & you fail to notify to the Practice, you could be financially responsible for services rendered. In the event of default & referral for collection, you agree to pay a surcharge of the outstanding balance plus a 33% collection fee.
Under the “No Surprise Billing” rule, uninsured (and self-pay) patients have the right to obtain a good faith estimate.
If you are having financial hardship, the Practice does have hardship policy. For patients without health insurance coverage for a service who elect to make payment at the time of service, we are able to offer a "prompt pay" discount from our standard (usual and customary) office fee schedule. The discounted amount must be paid in full at time of service each and every time and is only for patients without health insurance coverage for a service. Additional details on these programs are available upon request.
Laboratory Services:
The Practice uses third parties for laboratory and pathology services (i.e. Quest, LabCorp, Johns Hopkins Pathology). You/your insurance will receive an additional bill from these laboratory service providers. The Practice is unable to adjust these charges as these are provided by a separate entity.
Prior Authorizations:
Some insurance carriers require prior authorizations for medications and/or treatments. These prior authorizations will be submitted in a timely manner by the Practice, however the Practice can not control how long insurance carriers will take to process these prior authorizations.
Communications:
I agree to allow email, phone and text for communication with the office including but not limited to scheduling appointments, medication refills, photos, biopsy/lab results, treatment plans, authorizations and referrals. I understand the inherent risks of communicating health & financial information via unencrypted email and/or text & hereby consent to receive such communications despite those risks. I also hereby acknowledge that when the practice sends me an email, or I send an email to the practice, the information that is sent is not encrypted. This means a third party may be able to access the information since it is transmitted over the Internet. The same applies to text messages. This authorization will remain in effect until revoked by me in writing.
Medication Refills and History:
Medication refills will be responded to within 48 business hours. For oral medications, biologic (injectable) and some topical medications, the patient needs to be evaluated every 6 months. The Practice will not refill medications if the patient has not been seen within 12 months. You will be asked to sign a stand-alone consent that allows SureScripts, a industry wide secure nationwide pharmacy network to retrieve your medication history.
No Show Policy:
As a courtesy to both the office and fellow patients, it is expected that you will keep your scheduled appointments. If you need to cancel and/or reschedule an appointment, we request at least 24 hours notice. The Practice reserves the right to charge no show fees as below if canceled less than 24 hours before appointment and/or if the appointment is not kept. Fees must be paid before rescheduling. No show fees are the responsibility of the patient and will not be billed to insurance and my signature acknowledges receipt of notice of No Show fees. No show fees for office visits with Dr. Richard will be $25. After 3 'No Show' for scheduled appointments for phototherapy treatment, there will be a $25 fee.
Assignment of Benefits:
I hereby assign and authorize my insurance carrier including Medicare, other government sponsored insurances of which I may be covered and/ or all commercial payors to make payments on my behalf directly to the Practice, Elisabeth G. Richard MD, PA, for services rendered. I also assign any Medigap benefits to be paid directly to my provider. I permit a copy of this authorization to be used in place of the original. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services.
I have read and have been advised to read the entire Financial, Credit Card On File and Office Policies of Elisabeth G. Richard, MD, PA. Printed copy available at the front desk and also posted on the Practice website, www.lightandlaser.com.