Santiago Centurion, M.D.
Stanley
DERMATOLOGY J. Schnall, M.D.
ASSOCIATES OF CENTRAL NJ
3548 Route 9 South, 1st Floor,
28 Throckmorton Lane Suite
∙ Old OldRebecca
2 •Bridge,
Bridge, NJ Lu,
NJ 08857 ∙ M.D.
08857 • Tel.:
Tel.: (732)(732) 679-6300
679-6300 ∙ Fax:• (732)
Fax: 679-9566
(732) 679-9566
250 South Street • Freehold, NJ Iris Dubetsky,
07728 P.A.C
• Tel.: (732) 780-7870 • Fax: (732) 252-9703
www.dermatologyassociatesnj.com
OUR ITERAL FIACIAL POLICY AD WHAT ACCEPTIG ISURACE ASSIGMET MEAS:
To Our
must Patients:
Government Issue photo ID
Selfpay patients are required to make full payment up front at the time of your visit.
In our efforts to go green and keep the cost of healthcare down we have implemented the following
policy.
If we are providers
o enrollment for your insurance company, you will be asked for a credit card number at the time
forms
you check in and the information will be held securely until your insurances have paid their portion and
notified us of your financial responsibility. At that time, any remaining balance due to Dermatology
ote:
Associates of Centralwill not process
NJ will be charged to your credit card.
If we are NOT providers for your insurance
plan, the office policy remains the same: you will pay in full at the time of your visit. It is in your best
interest to understand your insurance plan.
YOU
This credit card policy AREwillRESPOSIBLE
be an advantage TOtoHAVE
you asTHIS
you O
willHAD BEFORE
no longer have toYOU ARE SEE
prepare and mailBY us
THE
checks.IfItyou
DOCTOR. willare
beseen without a referral
an advantage to usthere will since
as well, be an administrative
it will greatlyfee of $200.00
decrease theapplied
numberto your account. that
of statements
we have to generate and post in the mail. This policy benefits everybody by keeping the cost of healthcare
any
down, and by allowing us to concentrate first and foremost on your medical
needs.
Our credit card on account policy in no way will compromise your ability to dispute a charge or question
your insurance company’s determination of payment.
any personal changes that occur; (i.e. name, address, insurance name, guarantor, phone number,
etc) Co-pays,
you must Co-insurances,
fill out new forms. You
and will also need
deductible to update
amounts will,your personal
of course, information
still on atime
be due at the yearly
of basis.
your visit.
Please note, any charges over $100 will receive a courtesy call to advise that we will be charging
this to your credit card on file.
If you have any questions, please do not hesitate to ask.
*********************************************************************************************************
I authorize Dermatology Associates of Central New Jersey to charge outstanding balances on my account
to the following credit card. If the billing address for this credit card differs from your home address,
will be
please advise us of the billing address. Thank you.
Visa ___ MC ___ AmEx ___ Discover ____
CC Number Last 4 digits only _______________________________ Exp Date _____/_____ Security Code _________
Name on Card (Print) _______________________________________ Primary Phone # _____________________________
Patient Name _________________________________________________ Patient DOB __________________________________
Signature __________________________________________ Date ________________
Signature Date
