Insurance and Referral Forms

Thank you for choosing Sica Family Dermatology for your skin care needs. We offer a wide range of medical, and surgical dermatological services, and we will be happy to address any concerns you may have in these areas.

We offer a convenient way for preparing yourself for your first visit to our clinic. You may print the forms, complete them prior to your visit, and bring them with you, fax them to 509-834-7094, or e-mail to sica@sicadermatology.com. E-mailed or faxed forms will take anywhere up to 48 hours to get into our system.

Please bring any previous medical records that may be beneficial or pertinent to your visit. You may also request that your records be faxed to us prior to your visit.

Our goal is to schedule appointments in an efficient and timely manner. Please call us at least 48 hours in advance should you need to cancel or reschedule. If you miss your appointment without advance notification, your account is subject to a fee.

Insurance and Financial Policies

Understanding your financial responsibility is an essential component in establishing and maintaining a strong patient/practice relationship. In order to achieve this, we offer the following information regarding our insurance and financial policies.

Fees
Should you have any concerns regarding our fees, please speak with our office.

Non-Contracted Commercial Insurance Carriers

Sica Family Dermatology will file your “out of network” insurance claim as a courtesy. You will want to confirm with your insurance carrier that you have an “out of network” benefit, and how that benefit affects deductible, coinsurance and your financial responsibility. Outstanding balances will be billed to the patient as “due and payable” 30 days after the claim is filed.

Medicare

Sica Family Dermatology files claims and accepts assignment on Medicare. We are happy to file all secondary and supplemental claims as a courtesy. In the case of non-contracted secondary carriers, the balance will become patient responsibility 30 days after that claim is filed. If required by your secondary carrier, you will need to obtain referral or authorization prior to your appointment.

Medicaid/AHCCCS

Sica Family Dermatology is not contracted with any AHCCCS plan. Any patient covered under AHCCCS seeking services at Sica Family Dermatology would need to sign an “out of network” waiver indicating his or her understanding that he or she is solely responsible for payment. Payment, as with all private pay patients is due at time of service.

Private Pay Patients

Payment is due in full at the time of service. However, we may not be able to assign a final fee for procedures that necessitate the processing of pathology. In such cases, a deposit of $250.00 is required at the time of service. Following the reading of pathology, a final fee can be determined. A statement will then be generated and sent to the patient or guarantor for any remaining balance. Payment is due upon receipt.