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Please see your facial professional before beginning any facial treatment. There is a $25 fee NOT covered by any coupon presented upon service. This fee is for your required facial consultation in order to complete your procedure today.
The following are our conditions of registration as well as our policies with respect to the billing and collections of your account. By signing below, you are agreeing to be bound by these terms.
All co-payments, coinsurances and deductibles are due at the time of service. As a policy we will collect $45 at the time of visit to cover a portion of any consultation, coinsurance or deductible that may be due as we cannot determine these actual amounts until the claim has processed by our office manager. We will can bill insurance carriers on your behalf if we have a current contract with the carrier. After your insurance has processed the claim, we will be able to determine whether any refunds are due for overpayments towards copayment, coinsurance or deductible and those will be sent to the patient. Please be advised that your agreement with your insurance carrier is a private one and that ultimately, you are responsible for payment. If an insurance carrier has not paid a claim within 30 days of billing, our fees are due and payable from you. Our office will always strive to help you obtain the maximum possible coverage. It is, however, the patient's ultimate responsibility to determine the extent of coverage allowed by the insurance company.
In addition, preauthorization of a procedure is not a guarantee for payment. Any procedure may be considered not covered under the terms of your agreement with your insurance company. Your insurance carrier will make a determination of payment once the claim is received and reviewed. If after the claim is reviewed and it is determined by your insurance company that the procedure is not covered (cosmetic), you will be financially responsible to TLC Butterfly Effect Spa, LLC for the charges and will be billed for those services not covered by your insurance company.
In fairness to other patients and the doctor, we require at least 24 hours notice to cancel an appointment. You may be charged $50.00 for each appointment that was missed or not canceled with 24 hour notice. Missing more than two appointments without providing 24 hours notice is grounds for discharge from the practice.
There will be a fee of $35.00 charged by this office for each check returned to us by your bank.
I have read, understood, and agree to be bound by the terms of this policy.
I hereby acknowledge that I had the opportunity to review the Notice of Privacy Practices of TLC Butterfly Effect Spa, LLC. I understand that the Notice of Privacy Practices sets forth my rights relating to the use and disclosure of my personal health information and explains how TLC Butterfly Effect Spa, LLC can use and/or disclose my personal health information both with and without my authorization. I understand that I am entitled to receive a copy of the Notice of Privacy Practices* if I so desire. I further understand that I may contact Coach Scott if I have any questions regarding the contents of this Notice of Privacy Practices or to file a complaint about the privacy practices of TLC Butterfly Effect Spa, LLC.
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