BioHealth Dermatology

Financial Responsibility Agreement

For HMO-Insured Patients Proceeding Without a PCP Referral

  1. 1.
    No Referral on File

    I do not currently have a referral from my primary care physician (PCP) for this consultation. I understand that my health maintenance organization (HMO) plan generally requires a PCP referral for specialist visits, and that without one, my insurance plan may not cover this service.

  2. 2.
    Election Not to Bill Insurance

    I am choosing to proceed with this consultation without a referral. I understand that BioHealth Dermatology will not submit a claim to my insurance plan for this visit, and that I have the right to make this choice for any service I pay for in full out of pocket.

  3. 3.
    Financial Responsibility

    I understand that I am personally and fully responsible for the cost of this consultation. The fee for this visit is a discounted rate of $19, due at the time of service. I understand this amount is not an estimate contingent on insurance and will not be adjusted based on what my insurance plan might otherwise have paid.

  4. 4.
    Voluntary Choice

    I understand that I had the option to obtain a referral from my PCP before this visit, or to reschedule my appointment in order to do so, and that I am choosing to proceed today without one.

Note for patients with an active PCP referral: If you have an active, approved referral from your Primary Care Physician on file, this agreement does not apply to you. Our office will submit a claim to your HMO insurance at no additional cost. Please contact us at (888) 367-1850 before your appointment to confirm your referral is on file.
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