FINANCIAL POLICY STATEMENT
Your insurance plan is a contract between you and your health insurance company. It is your responsibility to know your benefits and the limits of your coverage. We ask that payments, including any applicable deductible, co-payment, or co-insurance, be made at the time of service unless other arrangements have been made in advance. For your convenience, we accept cash, check, money orders, debit cards, and most credit cards. You acknowledge that the amount paid for co-insurances and deductibles are an estimate and the actual amount may vary after the claim has been process. You acknowledge and agree that any payments due to the office will be paid in full and you understand any payments owed to you will be sent via check.
Patients with HMO or POS Insurance: If you are a member of an HMO or POS plan, you need to have a valid referral from your primary medical doctor for each office visit and surgical procedure. Prior to your visit, please call in advance to ensure that all necessary forms and authorizations are in place. Without a valid referral, financial responsibility will lie upon the patient, and full payment will be due at the time of service.
Late Payments: It is our policy to render periodic statements for services on a monthly basis. We reserve the right, at our option, to charge interest on outstanding balances beyond 2 months at a rate of 5% per month. All balances 3 months past due will be sent over to a collection agency and a 25% collection fee will be added to the outstanding balance. In case of credit card disputes, we reserve the right to submit this financial agreement as proof of contract for the financial responsibilities as outlined above.
Returned Checks: Returned checks will incur an additional $35 fee.
PATIENT AGREEMENT AND AUTHORIZATION
I hereby authorize Lee Aesthetic Center, LLC, its Doctors, and/or agents to apply for reimbursement benefits on my behalf for services rendered to me. I understand that payment from my insurance carrier will be made directly to Lee Aesthetic Center, LLC. I further authorize the release of any information necessary to process any claim with my insurance carrier. I understand that I am financially responsible for all charges, including co-payments, deductibles, and charges for non-covered services by my health insurance. I further understand that I will be responsible to pay for any service denied by my insurance company. In case of credit card disputes, I understand and accept that Lee Aesthetic Center reserves the right to submit this financial agreement as proof of contract for the financial responsibilities as outlined above. I permit a copy of this authorization to be used in place of the original.
By signing the consent form, I affirm I have read and understand the payment policy and agree to abide by its guidelines.
MEDICARE AUTHORIZATION
All Medicare patients must sign lifetime beneficiary claim authorization: I request that payment of authorized Medicare benefits be made either to me, or on my behalf, to Lee Aesthetic Center, LLC, and/or Dr. Henry Lee for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable to related services. I understand my signature requests that payment be made, and authorizes release of information necessary to pay the claim. If other health insurance is indicated in Item 9 of the electronically submitted claims, my signature authorizes release of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for deductibles, copays, and non-covered services. Co-insurance and the deductibles are based on the charge determination of Medicare carrier.
ACKNOWLEDGEMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have received an email copy of the Lee Aesthetic Center, LLC, Notice of Privacy Practices effective May 16, 2016.