Alaska Family Dermatology Price Sheet

In accordance with Alaska law 7AAC 860.020 & 7AAC 860.030, we are posting the Fee Value for our most common
office visit charges & procedures. Note: this is the Fee Value charged, not the negotiated rate for your insurance
company. It also may differ from the Cash Pay rate. This is not a guarantee of your visit charges, only an estimate. If
you would like to receive a good faith estimate, you must provide in writing to Alaska Family Dermatology, LLC the
following:

1. Patient’s full name
2. The Medical Condition or service for which the patient is seeking medical treatment
3. The method by which the patient prefers to receive the estimate, including a written letter
   mailed to the patient, by electronic means, or orally
4. The Patient’s Contact information, including the patient’s mailing address, electronic mail
   address, or telephone number
5. A parent or guardian of a minor patient must provide the above in writing to Alaska Family
   Dermatology, and in addition:
6. The parent or guardian’s contact information, including the parent or guardian’s mailing
   address, electronic mail address, or telephone number.

“CPT©2021. American Medical Association. All rights reserved. CPT is a registered trademark of the
American Medical Association. The CPT codes are provided ‘as is’ without warranty of any kind. The
AMA specifically disclaims all liability for use or accuracy of any CPT codes.”