Patient Resources > Registration Forms
* Please be advised these insurance plans require a referral from your Primary Care Physician, and in most cases, the referrals need to be entered by the Primary Care Physician’s office in the insurance’s online portal for referrals prior to the visit, in order for the referral to be valid and reimbursement to us be considered. If we do not receive or are unable to retrieve your referral prior to your appointment, you will be responsible for payment for services rendered at the time of the visit, as a self-pay patient. If a referral is obtained after the visit, we will reimburse you the self-pay fees once your insurance carrier processes your claim.
We do accept many commercial insurance plans; if you do not see your carrier listed, please contact your insurance carrier to see if we are in your network.
In the event that my insurance will pay all or part of the physician’s charges, the physician who renders service to me is authorized to submit a claim for payment to my insurance carrier. The physician’s office is not obligated to do so, unless under contract with the insurer or bound by a regulation of a State or Federal agency to process such claim, and if pertinent insurance coverage information is presented at, or prior to the time of the appointment. Aspire Dermatology will expect payment of co-pays, deductible portions, and co-insurance at the time of service. A $5.00 administrative fee will be assessed when patients request to delay co-pay, deductibles and co-insurance payment. Patients with an outstanding balance older than 90 days must make arrangements for payment prior to scheduling appointments. In the absence of a payment plan, collections fees will be applied to the account, and the account will be turned over to a collections agency. Aspire Dermatology accepts all major credit cards as a form of payment for your convenience. We realize that patients have financial difficulty and our financial counselors will work with you to ensure you receive needed medical care. Please note that Aspire Dermatology and its providers are considered “specialists” and co-pays are generally higher than the co-pays paid to Primary Care Physician.
A bill from the processing laboratory will be sent to you if any lab work or biopsies are performed during your visit, per your insurance contract. This bill does not come from Aspire Dermatology. This is an outside bill. Please note that special stains for biopsies may be needed. The dermatopathologist may need to request that an outside lab perform more intensive studies to insure a proper diagnosis. These separate additional costs include, but are not limited to, ordering special stains. You may be responsible for additional laboratory co-pay amounts that are determined according to your insurance plan benefits. Please be advised the decision to engage a third party laboratory for special stains is not made by Aspire Dermatology, and any additional monetary responsibility resulting from additional testing is owed to the respective laboratory. Any inquiries regarding additional laboratory co-pay amounts should be directed to the respective third party laboratory.
Non-sufficient Funds Fee:Aspire Dermatology will charge a $30 NSF fee in the event of a returned or bad check for any and all reasons. The patient will have to make arrangements for all future visits to be paid for either by cash or credit card; a check will no longer be accepted. Please note that as the depositor of the check, Aspire Dermatology gets charged a fee by our financial institution.
Missed Visits: Broken appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. A $25.00 missed appointment fee will be added to your account if you do not provide us with the requested 24-hour cancelation or rescheduling notice. A $75.00 missed appointment fee will be added to your account for missed or rescheduled Mohs surgery appointments under the 24-hour notice.
HMO Insurance Plans: For purposes of claim processing, Aspire Dermatology needs referring information from the patient such as referring physician’s name, address and phone number, and the referral form. Without the information, the claim will not process and the bill will be the responsibility of the patient. If you have an HMO coverage, you are required to get a referral prior to your visit at Aspire Dermatology. If a referral is not obtained prior to the visit, any financial obligations will be billed to the patient.
Insurance Eligibility & Benefits Verification:Aspire Dermatology is dedicated to assisting our patients with precise benefits coverage, by making efforts to verify eligibility and benefits for each patient’s insurance policy for any financial obligation, if any, resulting from that date of service; however we will not be liable for any inaccurate information provided to us wherever the information is available. Policies and coverage determinations may vary from payor to payor, plan to plan, and year to year, even if member ID’s and ID cards stay the same. Also, not all services are covered in all insurance plans. Please contact the member services department of your insurance company with additional questions regarding your policy and coverage.
SELF PAY PATIENTS: Please be advised if you have no insurance coverage, you are expected to pay for the “Office Visit” and treatment at the time of your visit. There could be additional fees for treatment performed the day of your visit. Those fees are expected to be paid the same day, or may be invoiced after charges for services rendered are determined.
If there is any lab work or biopsies done during your visit, you will receive a bill from the processing Laboratory. This bill does not come from us. This is an outside bill.
RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS:I hereby assign benefits to be paid on my behalf to Jason Michaels, MD, or other physicians who render service to me. The undersigned individual guarantees prompt payment of all charges incurred for services rendered or balance due after insurance payments in accordance with the policy for payment for such bills of Jason Michaels MD for charges not paid for within a reasonable period of time by insurance or third party payer. I certify that the information given with regard to insurance coverage is correct. I authorize Jason Michaels MD to release all or part of my medical records where required by or permitted by law or government regulation, when required for submission of any insurance claim for payment of services or to any physician(s) responsible for continuing care.
The undersigned certifies that he/she has read and understands the foregoing and full accepts all terms specified above.