Direct Pay Policy at Perfect Skin Dermatology

Perfect Skin Dermatology​ is a direct pay-only medical practice. Please read and agree to the following:

PAYMENT:​ Payment in full is due at the time of service.

We do not accept Medicare, Medicaid, Tricare or private medical insurance. At appointment scheduling, a credit card on file with prior authorization or cash deposit is required. Any additional charges will be discussed with you prior to charging. Missed visits without 24-hour notice will result in a charge of $100.00 or the visit fee, whichever is less.

According to Federal Law, any patients on Medicare, including Medicare supplements, must sign a private contract before being treated at our office. If you are eligible for Medicare, or transition to Medicare during your care, you will need to sign a separate agreement. Our private contract for Medicare beneficiaries can be found on our website under “​Your Visit​” and needs to be renewed every two (2)years.

1. I have been informed that neither ​Perfect Skin Dermatology​, nor Dr.Schroeder participates in health insurance, HMO plans or panels. I have also been informed that Dr. Schroeder has opted out of Medicare as of July 1, 2020.
2. Perfect Skin Dermatology​ makes no representation that any fees paid to ​PerfectSkin Dermatology ​are covered by my health insurance or other third-party payment plans.
3. I understand that Dr. Schroeder has opted out of Medicare as of July 1, 2020, and consequently, Medicare cannot be billed for any services performed for me at ​Perfect Skin Dermatology​. I agree not to bill Medicare or attempt Medicare reimbursement for any such services.

I understand and agree to the above,

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Patient signature (or responsible party)