Good Faith Estimate 

This is a Good Faith Estimate of the expected services provided by Skin Cancer and Cosmetic Dermatology Center (SCCDC).  SCCDC does not yet know the correct diagnosis codes for your visit. However, we are required to provide a good faith estimate. Listed below are the most common types of services a patient may receive during a visit to our practice.  The fee charged is based on the visit type, patient type, and the payment group the patient falls within on the sliding scale.

Using the chart below, determine your Visit Type (Medical) and Patient Type (New or Established).  Once you have determined the Visit type and patient type, use the sliding scale to determine your payment group. Group A, B, C, D and E are part of the Sliding Scale program and to receive that pricing, a person must apply for the sliding scale and be approved.  Group F is regular pricing if a patient isn’t approved for sliding scale.  Please use the information on the following page to help you determine if you qualify for the sliding scale.

Use Our Estimator

Select Household Size
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Your Estimated Cost
Level 2
Level 3
Level 4
$30.00
New Patient
Level 2
Level 3
Level 4
$20.00
Existing Patient
Level 2
Level 3
Level 4
$40.00
New Patient
Level 2
Level 3
Level 4
$30.00
Existing Patient
Level 2
Level 3
Level 4
$50.00
New Patient
Level 2
Level 3
Level 4
$40.00
Existing Patient
Level 2
Level 3
Level 4
$40.00
New Patient
Level 2
Level 3
Level 4
$30.00
Existing Patient
Level 2
Level 3
Level 4
$50.00
New Patient
Level 2
Level 3
Level 4
$40.00
Existing Patient
Level 2
Level 3
Level 4
$60.00
New Patient
Level 2
Level 3
Level 4
$50.00
Existing Patient
Level 2
Level 3
Level 4
$50.00
New Patient
Level 2
Level 3
Level 4
$40.00
Existing Patient
Level 2
Level 3
Level 4
$60.00
New Patient
Level 2
Level 3
Level 4
$50.00
Existing Patient
Level 2
Level 3
Level 4
$70.00
New Patient
Level 2
Level 3
Level 4
$60.00
Existing Patient
Level 2
Level 3
Level 4
$60.00
New Patient
Level 2
Level 3
Level 4
$50.00
Existing Patient
Level 2
Level 3
Level 4
$70.00
New Patient
Level 2
Level 3
Level 4
$60.00
Existing Patient
Level 2
Level 3
Level 4
$80.00
New Patient
Level 2
Level 3
Level 4
$70.00
Existing Patient
Level 2
Level 3
Level 4
$92.25
New Patient
Level 2
Level 3
Level 4
$71.21
Existing Patient
Level 2
Level 3
Level 4
$137.02
New Patient
Level 2
Level 3
Level 4
$111.77
Existing Patient
Level 2
Level 3
Level 4
$205.64
New Patient
Level 2
Level 3
Level 4
$159.00
Existing Patient
Ultimately your patient level will be determined by one of our providers.

What Are Patient Levels & How To Know Which Levels Is Mine?

Ultimately your patient level will be determined by one of our providers.

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Level 2 Visit
Example Medical Issue - One Minor Problem.

Complexity - Straight Forward Medical Decision Making.

Provider Involvement - The Provider is Only Monitoring.
Level 3 Visit
Example Medical Issue - 2 Or More Minor Problems OR 1 Stable & Chronic Problem.

Complexity - Low Medical Decision Making.

Provider Involvement - The Provider is Monitoring, Referral To Outside Specialist, Advisement.
Level 4 Visit
Example Medical Issue - 2 Or More Stable & Chronic Problem OR 1 Chronic Problem That Isn’t Stable.

Complexity - Moderate Medical Decision Making.

Provider Involvement - Prescription Management, Surgery, Monitoring, Referral To Outside Specialist, Advisement.

How Skin Cancer and Cosmetic Dermatology Centers Determines Your Payment Group 

This estimate is for patients that both decide to participate in the Sliding Scale program and qualifies for the program. Payment Groups are based on the number of people in the household and total income, using the chart below.

Sliding Scale Prices
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*Sliding fee schedule is updated annually to reflect any changes in DHHS Federal Poverty Guidelines.

SCCDC is pleased to offer a sliding fee discount program to qualifying individuals.  If an individual qualifies for the program, charges may be adjusted down to a nominal fee.  This nominal fee is due at the time of service.  Sliding scale status is only good for one year from the date of application and must be recertified annually on the anniversary date.
   
Sliding fee discount program status can also be adjusted for change in income or household size.  To apply, an individual must provide two pieces of information.
 
Sliding Fee Application – Available at each front desk

Proof of Monthly household income – Patient provides

Examples of acceptable income information:

Tax return from the previous year (if self-employed, tax return plus Schedule C)

Most recent check stubs – 4 stubs for weekly pay or 2 stubs for bi-weekly pay

Notarized letter from employer (for odd jobs, etc.)

These two pieces of information must be provided to the office before an individual may be considered to be on the sliding fee program.  All paperwork must be turned in at the same time, not piece by piece.  The individual is responsible to pay in full on the date of services for all charges incurred until qualified on the sliding fee program.  

Good Faith Estimate - Disclaimer

This Good Faith Estimate shows the cost of items and services that are reasonably expected for your health care needs.  The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment.  You could be charged more if complications or special circumstances occur.  If this happens, federal law allows you to dispute (appeal) the bill.  If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the health care provider or practice listed to let them know the billed charges are higher than the Good Faith Estimate.  You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

If you are billed more than $400 above the amount on this Good Faith Estimate, you may also start a dispute resolution process with the U. S. Department of Health and Human Services (HHS).  If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) from the date on the original bill.  There is a $25 fee to use the dispute process.  If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate.  If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount.

For questions, to learn more or get a form to start the dispute resolution process, go to www.cms.gov/nosurprises.