New Patient Forms

This Privacy Policy (the “Policy”) explains how Aesthetic Solutions (“us,” “our,” or “we”)collects, uses, discloses, and protects information that we collect from you when you visit our location and obtain services from us (the “Services”). Effective October 1, 2020.

Information We Collect About You

When you use or access the Services, we may collect personal information, such as the following:

• Contact information, such as name, email address, or phone number.

• Information you submit when you contact us or visit our location.

• Information pertaining to the Services we provide you, including information necessary to facilitate and pay for the services you receive.

• Information pertaining to the Services you have expressed an interest in.

 

How We Use Your Information.

We may use personal information that we collect about you for purposes that include the following:

• Providing the Services to you.

• To communicate with you and respond to requests.

• Understanding how you and others use our Services and to determine what features and services may interest you and others.

• Operating, evaluating, and improving our organization.

• For analytics, marketing, or advertising purposes.

• Storing information about your preferences and recognizing you when you obtain Services.

• Protecting the legal rights, property, safety, and security of us and you, including to comply with applicable law and industry standards and to enforce our policies, terms of use, or rights arising from contracts.

• For such purposes as you may authorize at the time you submit the information.

Disclosure of Your Information

We may disclose personal information we collect about you:

•To communicate with you.

• To our affiliates, business partners, contractors, service providers, and other third parties we use to support our organization, including those we contract with to provide analytics, marketing, or advertising services.

• To comply with any court order, law, or legal process, including to respond to any government or regulatory request.

• To enforce our policies, terms of use, or rights.

• To investigate or prevent unlawful activities and to protect the rights, property, or safety of us, our clients, or others.

• To a buyer or other successor.

• For such purposes as you may authorize at the time you submit the information.

Changes to this Policy

We may update this Policy to reflect changes in our privacy practices at any time without prior notice to you. When we do so, we will update the Effective Date of the Policy, above. Contacting Us If you have any questions or comments about this Policy or our privacy practices, please contact our Practice Manager at 919-403-6200, or 5821 Farrington Road, Chapel Hill, NC 27517.

Thank you for choosing us! We are committed to assuring an exceptional experience with our practice and hope this information will be helpful to you.

Consultation with a Physician

We charge $150 for all office visits with a physician. This covers evaluation, diagnosis and recommendations. Additional services are billed separately, and all costs will be explained prior to treatment. The office visit charge will be waived when an injectable treatments are performed during the same visit.

Consultation with a PA

We charge $100 for all office visits with a physician. This covers evaluation, diagnosis and recommendations. Additional services are billed separately, and all costs will be explained prior to treatment.

Consultation with an Aesthetician

We do not charge an office visit for a consultation with our aestheticians. The aesthetician will confer with our physicians, and a physician may stop by to confirm the aesthetician’s recommendation. This is not a cosmetic consult and will not include an evaluation of issues unrelated to the purpose of your appointment.

Treatment Package Pricing

Some services require multiple treatments for maximum benefit and are offered as packages at a reduced cost. Payment for that package is required prior to or at the time of first treatment. If you do not complete all treatments, we will re-calculate the cost of completed treatment at the single treatment rate, and refund or credit your account the unused portion.

Skin Care Products

We recommend medical-grade skincare products with clinically proven benefits. We sell these products in our office, but you may find the same or comparable products elsewhere (please be sure they are unexpired, genuine products that have been stored properly). Opened products may not be returned. Refunds will be given for return of unopened products within 30 days of purchase. Please note all prescription products require an office visit to obtain a prescription. Prescription products cannot be shipped. Prescription products may not be returned once they leave the practice.

Missed Appointments / Late Cancellations / Procedure Deposits

Our office requires 24 hours notice to cancel or reschedule an appointment. For New Patient appointments we require a deposit in the amount of the provider's consultation fee to hold the appointment time. The deposit is fully refundable if the appointment is canceled with 24 hours notice. For appointments canceled with less than 24hours, or no-showed, the deposit is forfeited. For existing patient appointments, we charge $50 for missed appointments and appointments canceled with less than 24 hours of notice. Some appointments require a deposit, and may have longer notice requirements. For those appointments, you forfeit your deposit if you late cancel or no show the appointment. The deposit and notice period will be included in the quote offered for your treatment. We will reach out to confirm your appointment 7 days prior, 3 days prior and 24 hours prior by text and/or email. We telephone if you do not respond to these reminders. We reserve the right to cancel your appointment if you do not respond to these reminders.

Late Arriving Patients

Patients arriving more than 15 minutes late will be rescheduled. Finance Charges / Returned Checks We charge interest of 1.5% monthly (18% APR) on unpaid balances, beginning 30 days from the date you are invoiced. We will charge your account $30.00 for each returned check. If two (2) or more of your checks are returned by your bank unpaid, only cash or credit cards will be accepted for future visits.

I have received a copy of the Financial Policy. I understand and agree I am financially responsible for all amounts due Aesthetic Solutions. I authorize the release of my personal health information as necessary to collect payment. We accept cash, check, major credit cards and Care Credit for charges over $500. Care Credit terms and conditions do apply. I have read and understand this Financial Policy, and agree I am personally responsible for payment. I agree to the release of my personal health information as necessary to collect payment. I understand Aesthetic Solutions does not accept any commercial or government5 / 7provided insurance, and does not communicate with, or coordinate care with any insurance company. I understand I will be offered an itemized receipt for services. If I have any questions about this Financial Policy, I understand I may contact the Practice Manager at 919-403-6200.

Aesthetic Solutions is committed to providing effective, discreet, and compassionate service to every patient. We conduct ourselves in an ethical manner, and do not discriminate against patients based on gender, age, race, religion, or sexual orientation. We will accommodate non-English speaking patients to the best of our ability. Patients have the right to choose their health care provider. We will help patients access their desired provider to the best of our ability, and facilitate any changes should they become desired. Patient confidentiality is a priority. We respect, secure, and protect the privacy of our patients’ medical records under the Department of Health and Human Services Privacy Rule under HIPAA (Health Insurance Portability and Accountability) Compliance Program. When appropriate and necessary, we provide only the minimum necessary to only those we feel are in need of your health care information and treatment. We have indirect treatment relationships with laboratories and other health care entities and disclose personal health information for treatment purposes, payment, or health care operations. You may refuse to consent to the use or disclosure of your personal health information in writing. Under this law, we have the right to refuse treatment should you choose not to disclose your personal health information. Our Notice of Privacy Practices is available at www.Aesthetic-Solutions.com or upon request from our office. For additional information, please ask to speak to Brisson Norris, our Practice Manager and our Privacy Officer. We support your full access to your personal medical records. You will be provided, to the degree known, complete information regarding your diagnosis, evaluation, treatment, and prognosis, unless it is medically inadvisable to give such information to you. You will have the opportunity to participate in decisions involving your health care, except when such participation is contraindicated for medical reasons. If it is medically inadvisable or contraindicated for medical reasons, information and the opportunity to participate will be provided to a person you designate or your legally authorized representative. It is your responsibility as our patient to (a) complete truthfully all required chart forms, including but not limited to your personal health history, financial policy, and pertinent consent forms; (b) arrive for your scheduled appointment on time and physically and mentally competent; (c) follow the prescribed treatment plan; (d) have dependable transportation to and from our office and adult supervision post-procedure when required by the provider; (e)inform the provider of any living will or other directive that could affect your care; (f) accept personal financial responsibility for any charges not covered by your insurance and pay for services on the day they are rendered; (g) treat our staff and other patients with respect; and(h) advise us at least 5 days in advance if a patient or responsible adult family member is unable to understand written and spoken English so we may arrange for a translator. Patients may express suggestions, complaints and grievances to Sue Ellen Cox, MD, President of Aesthetic Solutions in person, by telephone (919-403-6200), by email(sec@aesthetic-solutions.com), or through patient satisfaction surveys. Patients may also contact the North Carolina Medical Board (919-326-1100, www.ncmedboard.org) or Medicare(800-633-4227, www.medicare.gov). Our patients can expect our physicians and staff will work diligently to provide medical and cosmetic dermatology treatment in a warm and friendly atmosphere with the highest possible standard of care.