You are required to pay your copay at time of visit.

Cancellation Policy: If you are more than 15 minutes late for your appointment and have to reschedule, or you do not have to provide notice of cancellation by 4:30 pm on the business day previous to your appointment, the cancellation fees are as follows: Medical Office Visit: $20.00, Surgical Visit: $100.00, Facial Visit: $75.00, Cosmetic Visit: Between $100.00 and $300.00 depending on the procedure.
If your insurance provider requires you to have a referral to be seen in our office, you are responsible for getting the referral.
Santa Rosa Skin Center will bill your insurance provider, directly for medical services rendered. You will be asked to provide a credit card number at check-in. If your benefit coverage includes coinsurance or deductibles, we will charge your credit card the amount your insurance provider indicates as your responsibility. We will always send you a receipt.
If your insurance denies the claim, you will be responsible for all outstanding bills. Our staff will work with you in an effort to collect the appropriate payments from your insurance provider. We are not responsible for policy coverage changes and incorrect or incomplete information provided by you at the time of registration or service.
Santa Rosa Skin Center's Notice of Privacy Practices has been made available for you on our website, santarosaskincenter.com.

Your signature below (1) certifies that the information you have provided on this form is correct , (2) authorizes Santa Rosa Skin Center to release medical information necessary to process insurance claims to insurance companies for the purpose of payment of medical claims, and (3) authorizes Santa Rosa Skin Center to use the credit card on file for your account.