Northside Facial Cosmetic Surgery Financial Policy

1. Payment is due at time of service for all in-office cosmetic procedures.
   
   
2. Full payment for cosmetic surgery is due at our office prior to surgery.
   
   
3. A NO-SHOW fee of $25.00 may be assessed for each appointment missed. Notify us at least 24 hours in advance to cancel or reschedule your appointment to avoid the penalty.
   
   
4. Any dishonored check will result in a $35 return check charge.
   
   
5. Our office collects an Administrative Services Fee (ASF) of $10 per year at your first visit of the year. These administrative fees are intended to cover the cost of certain administrative tasks not covered by insurance. If you choose not to pay the ASF, you will be charged for all non-covered administrative services including completion of FMLA, disability, and school forms as well as patient requested reports such as claims, statements, and payment histories. These will be charged at $50 per form.
   
   
6. Cosmetic Surgery Quote: After you and Dr. Majmundar have finalized your surgical plan, we will provide you with a quote for your surgery. The quote is an estimate and will include your initial consultation, the pre-operative visit, digital photographs, procedure fee, and all related follow-up appointments for 1 year. We will also provide you with an approximate quote for the facility fee, cost of implants if any (except for chin implants), and the cost of anesthesia as applicable.
   
   
7. We collect a non-refundable deposit of $500 or half of the procedure quote, whichever is less, to schedule and hold your desired date of surgery. You may schedule your procedure as soon as the day of your initial consultation.
   
   
8. Payment Options: Cosmetic procedures are an excellent investment in your medical and psychological well-being. To make your healthcare investment cost-effective, we provide the following payment options.
   
   
   • Cash or certified check
     
     
   • All major credit cards - VISA, MasterCard, Discover, American Express
     
     
   • Care Credit: Care Credit gives you convenient low monthly payment options so you can get the procedure you want now. This involves a simple one page application and immediate approval online. There are no up-front costs, no prepayment penalties and no annual fees.
     
     
9. Additional charges: Required lab work or additional operative time will be billed separately to you by the lab, surgery center, or hospital. We recommend that the patient be covered by health insurance at the time of the cosmetic surgery in the rare instance that a post-operative complication develops. All charges related to additional procedures for revisions or complications are the full responsibility of the patient.
   
   
10. Insurance Cases
    
    
    • For cases covered by insurance, all co-payments are due at time of service.
      
      
    • It is your responsibility to confirm our physicians participate in your insurance plan. If you see a physician that is not on your plan, you are responsible for all charges in full.
      
      
    • All medical records requests must be in writing and received 72 hours prior to the date needed. Records over 10 pages will be mailed not faxed and a fee will be assessed based on the number of pages ranging from $10 to $50.
      
      
    • If your balance becomes 60 days delinquent after insurance payments, your account may be sent to a collection agency. You are responsible for all collection fees incurred.
    
    
    
11. Cancellation Policy: We understand that a situation may arise that could force you to reschedule, postpone or cancel your surgery. Please understand that such changes affect not only your surgeon and staff, but other patients as well. We appreciate the courtesy of notification as early as possible in order to make the time available to other patients.