Thank you for choosing Chesterfield Valley Dermatology.
Please arrive 20 minutes prior to your appointment. Please bring the following items listed below:
Photo ID (ie…Drivers License)
Insurance Card(s) (Please remember you may be considered a self pay patient without an Insurance Card at the time of visit)
New Patient Information Forms
If you are a new patient or you have not seen one of our providers during this calendar year, please print and fill out the forms located at the bottom of the page.
All balances on your account must be paid before or at your next scheduled office visit. If balance is not paid or cannot be paid you will be asked to reschedule. Thank you for your understanding.
CVD Policy Information
Insurance/Payment: Current insurance card(s) and co-payment are expected at time of service. If you do not have your insurance card(s) at time of visit you will be considered a self pay patient. If your insurance requires a referral, it is your responsibility to acquire the referral before appointment date. If referral is not received before appointment date and you still want to be seen that day you will be considered a self pay patient. You are responsible for any charges incurred if you provide incorrect information or if you do not update any insurance changes at each visit. Each patient’s visit is accurately coded and documented to the best of our ability. Preventive care visits do not apply to dermatological services and are not used by our office. You are required to pay for all copay, coinsurance and deductibles at time of service. In the event that there is a remaining balance due after the claim is processed, you will be billed for the balance. Please understand that payment for these charges are due at the time the statement is received or at the time of your next office visit, whichever comes first. If you cannot pay your balance the day of your scheduled visit, you will be asked to reschedule. If you do not pay your balance when statement is received by mail you will accrue a $10 late fee every month an additional statement is mailed. There will be a $30 service fee on all returned checks.
Late Arrival/No Show: We value your time and make every effort to stay on schedule. If you are running late to your appointment, please call the office to notify us so we can accommodate or reschedule the appointment in consideration for other patients' appointment times. Please allow 24 hour prior notice should you need to cancel or reschedule an appointment. Failure to notify the office and not appearing for your office visit will result in a No Show charge of $35. Please note, we reserve the right to charge $75 for a missed surgery/procedure. FULL DETAILS ON THESE POLICIES HERE.
Minors: For your child's safety, a parent must accompany children to their initial visit. For additional visits, a written consent to be seen and treated without a parent is permitted. In Case of Divorce: The parent who brings the child is stating they have "joint legal custody" or "sole legal custody" and can make health care decisions for the child. The parent who brings the child is considered the Guarantor. They have accepted responsibility for the child and their charges. The statements will be sent to the Guarantor. It is expected that in the case of divorce the two parties will handle payment arrangements without the involvement of the office.
18 and Over: Once a patient turns 18 years of age, he/she must be put on an individual account due to HIPAA rules and regulations. The patient must give the parent(s), guardian(s), and/or other individuals permission to receive information regarding their medical and/or financial information. If the patient would like a parent/guardian to speak on their behalf or be accountable for their account, it must be in writing. Please understand, if the patient does not give written consent, no information can or will be released. If the parent/guardian does not give written consent to be the responsible party for the patient, the patient will be responsible for his/her own account. 18 and Over Patient Consents and CVD Policies & Permission to Relay Information (PRI)
Billing for Delinquent Accounts: If your account becomes delinquent (not paid after third billing statement), it will be referred to a collection agency. Accounts placed in collection will be assessed a 40% collections fee by the agency in addition to any attorney fees or court costs that may incurred in an attempt to collect the debt.
Forms Completion Policy: There is a $25.00 fee for completing any form or letter that is not directly related to the reimbursement of a medical service in our office. This includes, but is not limited to, FMLA, VA, life insurance and disability forms. The patient portion of the form must be completed and signed prior to acceptance, along with payment. Please allow a minimum of 7-14 days for completion.
All patients coming to Chesterfield Valley Dermatology or to Progress West Healthcare Center (Medical Office Building) need to have the New Patient Information completed when they arrive.
Please print and fill out the New Patient Information and bring it with you to your office visit. it is not necessary to print other forms, unless you need medical records transferRed or a copy of the HIPPA forms on filE.
**We accept most major insurance carriers, including Medicare. We also accept checks, Mastercard, Visa, Discover and American Express. Gift Certificates are also available.