Contact Information

Brookwood Dermatology
Phone: 205-588-7547
521 Montgomery Highway
Vestavia Hills, AL 35216

Gardendale
Phone: 205-824-4441
1603 Decatur Hwy
Gardendale, AL 35071

Pell City
Phone:  205-824-4441
70 Plaza Drive
Pell City, AL 35125

Monday-Thursday: 8 a.m. to 4 p.m.
Friday: 7 a.m. to Noon 

                                                     
 

Our Policy Regarding Patient Owed Balances


Fields marked with * are mandatory

Dear Patient,

This form and your signature below serves as formal notification of our patient balance policy.
Once we have received payment in full from your primary insurance company (and secondary carrier if you have additional coverage) you will receive a bill for the patient-owed portion of the bill. These balances are usually for unpaid copayments, non-met deductibles, or non-covered services per your particular plan’s benefits.

We will bill you once all charges for a particular date of service have been paid by your carrier(s). You may still have claims that are being processed for other dates of service. However, we bill you based on a specific date of service for which insurance payments have been received in full in order to clear the remaining balance for that date of service.

Due to the high volume of un-paid patient balances it is the policy of this office to send only two statements. The statements are sent at 30-day intervals. If no payment is received on your account during the 60-day period, your accounts will be turned over to collections without additional notice. We feel that two months is a reasonable amount of time to make payment on your account.

If your account is turned over to a collection agency, you agree to reimburse us the fees, which may be based on a percentage at a maximum of 33% of the debt, and all costs, and expenses, including reasonable attorneys’ fees we incur in such collection efforts.


For your convenience, accounts can be paid using your Mastercard, Visa, Discover Card or American Express. You can indicate your credit card information on the statement or call the office to make a payment.


Your signature on this form acknowledges your understanding of this policy.


 

____________                                                ______________________________

Date                                                                Patient or Guardian Name (printed)

 

                                                                        ______________________________

                                                                        Patient or Guardian Signature

 

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Brookwood Dermatology
521 Montgomery Highway, Vestavia Hills, AL 35216
205-588-7547

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