Cosmetic Fees Payment Policy:
Payment for Cosmetic fees and services are due, in full, at the time of service.
Payment, in full, for cosmetic consultations must be paid at the time of scheduling in order to reserve your appointment date and time. In order to provide a thorough and individualized exam and treatment plan no other conflicting appointments are scheduled during your cosmetic consultation, therefore, all cosmetic consultation fees are NON-REFUNDABLE. Your payment will be applied toward your final surgery payment if surgery is scheduled within six (6) months of your consultation, or toward any other cosmetic procedure or treatment (ex: Botox, Fillers, etc.) that you and your doctor have discussed that you may be a candidate for if you choose to receive treatment at the time of your consultation.
Payment for cosmetic surgery may be paid in full at the time of scheduling, or can be divided into payments consisting of: a NON-REFUNDABLE deposit of at least 10% of the total surgical fees due at the time of scheduling in order to book your chosen surgery date, and the remaining 90% balance paid in installments or in full by or at the time of your pre-op visit, which is typically scheduled for the date two (2) weeks prior to your surgery date. If your surgery was scheduled within six (6) months of your cosmetic consultation, then your $100 paid consultation payment will be applied toward the remaining balance due at the time of your pre-op visit.
The deposit amount is Non-Refundable once your date has been booked, even in the event of unforeseen circumstances. This policy is necessary and required due to the amount of time and effort required to coordinate your surgical care with attending surgical nurses and support staff (surgical tech and/or others providing assistance to the surgeon during your procedure), coordinating your care with any outside facility and anesthesia (if performed in an outpatient setting), the cost of ordering and maintaining all surgical supplies required for your procedure, and the additional expense of scheduling changes and/or inability to post an alternative surgical patient or the amount of clinical appointments required to fill the reserved surgical time block.
Your surgery may be rescheduled one (1) time if required, but a separate, non-refundable, 10% deposit will be required in order to book the new surgery date. Unfortunately, this policy is necessary and required due to the cost of surgery cancellation as listed above, which cannot be otherwise recouped, and is incurred by our office with each separate surgical booking.
For visits subject to insurance coverage: We will file medically necessary services to your in-network insurance carrier as a courtesy. Claims will be submitted according to AMA guidelines and according to any provisions as agreed upon for contracted carriers. Your current insurance card must be presented prior to your services in order for our staff to attempt to file your claim to your carrier.
Depending on the carrier, we may or may not be able to verify basic coverage information once your insurance card has been presented. Eligibility verification will inform us only that your policy is active or inactive. Eligibility information is not available for all carriers or at all times. Benefits information will provide us with your copay amount, coinsurance %, and the annual deductible amount. Benefits information is not available for all carriers or at all times. Not all insurance cards indicate the benefits coverage amounts. Your estimated patient responsibility is due at the time of service and may consists of your copay, coinsurance, and/or deductible, as well as fees for any services or procedures that do not meet "medically necessary" requirements (i.e. cosmetic services are not medically necessary). It is your responsibility to ensure that all criteria for coverage with your insurance carrier are met including verification of your provider's network status and all requirements for referrals, prior-authorizations, and medical necessity guidelines. Please check with your insurance plan for questions regarding your specific plan requirements or provider network status. There are hundreds of payers and plans and but each plan may have different guidelines, provider contracts, and coverage benefits, therefore, it is advised that you familiarize yourself with your current plan benefits. Our staff does not have access to your plan documents and will not be able to answer questions about your specific plan. Please check with your insurance plan for questions regarding your specific plan requirements or provider network status. Presenting your insurance card, filing your claim, or paying a copay do not guarantee coverage or payment by your insurance carrier, and do not further alleviate your responsibility for payment in full.
You are responsible for payment in full of your charges and/or to resolve any discrepancies concerning coverage or payment with your insurance carrier in a timely manner. All charges must be paid in full within 90 days of being incurred, regardless of pended or denied insurance claim status or dispute. Our office will make all reasonable efforts to ensure correct coding of your claim, and will provide any additional information requested for processing. We will make reasonable attempt to resolve any coverage or payment disputes for services which we believe have met coverage criteria, but you are ultimately responsible for payment for services provided regardless of insurance coverage.
My signature on this Financial Policy indicates that I have read, understand, and agree to the practice policy regarding insurance. My signature indicates that I agree to the submission of my incurred charges to my insurance carrier, and I assign all benefits to my provider.
Forms of PAYMENT Accepted: Payment is accepted in the form of: Cash, Check, Visa, MasterCard, Discover, Alle and Aspire Reward Coupons, and/or Gift Certificates issued by our office. Coupons and Discounts offered via rewards programs are subject to the terms and conditions of the program and offer(s). Our provider must be a participating provider at the time the reward program coupon is presented, and the coupon/discount must be redeemed by the program without incident when presented in order to be an accepted form of payment.
Returned checks/card transactions: All returned checks or card transactions will be subject to a $35 Returned Check fee. Our office may elect to require future payment in the form of credit/debit card or cash for accounts which have incurred a returned check fee.
Cancellation Policy: Appointments must be cancelled with at least 48-hour advanced notice or will be subject to a cancellation fee. Any request to reschedule your appointment within 48 hours of your scheduled appointment is a cancellation and is subject to the cancellation fee. Appointment cancellations within 48 hours and no-show appointment will result in a $100 cancellation fee for each appointment, and a $200 fee for in-office procedures, excluding surgery and procedures scheduled for our surgical suite which may be subject to a cancellation fee of 10% of the total surgical cost or $200, whichever is greater*.
Due to the amount of time and effort involved in coordinating surgery, any surgery cancellation will result in the forfeiture of the surgery deposit.* Rescheduling of a surgery date will be considered a surgery cancellation and will result in the forfeiture of your original surgery deposit. A new, separate surgery deposit will be required in order to secure your rescheduled surgery date.
*Waiver of these fees will only be granted for rescheduled appointments and surgeries due to approved medical reasons or special exception. Request for exception due to special circumstances can be requested in writing by mail, via message through our secure patient portal, by contacting us via the link on our website, www.SmytheRichMD.com, or by emailing your request directly to: email@example.com.
Outstanding balance & Collections Policy:
Any balance remaining after 90 days may be subject to collection activity and associated collection fees up to 35% of the overdue balance plus up to $25 in administrative fees. These fees may be billed to the patient directly by the collection agency. Your account may be reported to the credit bureau and may negatively affect your credit. Once your account has been sent to collections, our office may elect to deny future services or treatment until the account has been satisfied in full, including all associated billing fees, regardless of the age of the outstanding balance. Payment for future charges may be required in the form of credit/debit card or cash.