Claims Submission Certifications. I understand the information in this document or otherwise given by me to Certified Dermatologists will be used in submitting claims for payment for services rendered to me or the patient named below, and I certify that such information is correct. I authorize a copy of this document to be used in place of the original, and the use of “signature on file” on all claims submissions. I agree to notify Certified Dermatologists if any of the information I have provided in this document changes or is no longer accurate and understand that I am responsible for notifying Certified Dermatologists of the new or corrected information. I understand that I am responsible for notifying Certified Dermatologists of any pre-certifications or referrals required by my health plans or the health plans of the patient named below. In the event any account becomes delinquent and collection activity is required to collect payment, I agree to pay all reasonable attorney fees and collection agency costs and/or fees associated with the collection of any unpaid balance.
Claims Submission Certifications. I understand the informaﳳon in this document or otherwise given by me to Cerﳳfied Dermatologists will be used in submiﹹng claims for payment for services rendered to me or the paﳳent named below, and I cerﳳfy that such informaﳳon is correct. I authorize a copy of this document to be used in place of the original, and the use of “signature on file” on all claims submissions. I agree to noﳳfy Cerﳳfied Dermatologists if any of the informaﳳon I have provided in this document changes or is no longer accurate and understand that I am responsible for noﳳfying Cerﳳfied Dermatologists of the new or corrected informaﳳon. I understand that I am responsible for noﳳfying Cerﳳfied Dermatologists of any pre‐cerﳳficaﳳons or referrals required by my health plans or the health plans of the paﳳent named below. In the event any account becomes delinquent and collecﳳon acﳳvity is required to collect payment, I agree to pay all reasonable aﹷorney fees and collecﳳon agency costs and/or fees associated with the collecﳳon of any unpaid balance.
