Payment is required at the time services are rendered unless other arrangements have been made in advance. This includes applicable coinsurance, co-payments and surgical deductibles for participating insurance companies. Perimeter Plastic Surgery accepts credit cards, cash, CareCredit, & Alphaeon. There is a $35.00 fee for NSF. Patients with an outstanding balance 60 days or more overdue must make arrangements for payment prior to scheduling appointments & surgeries. Payment plans can be arranged if requested.
We bill participating insurance companies as a courtesy to you. You are expected to pay your deductible and copayments at the time of service. If we have not received payment from your insurance company within 90 days of the date of service, you may be expected to pay the balance in full. You are responsible to be sure all charges are paid whether by you or your insurance carrier. All Medicare patients are required to fill out an ABN for all surgical procedures & office visits. Patients who are enrolled in a managed care insurance plan (i.e., HMO),must receive a referral from their primary care physician prior to coming to our office. Retroactive referrals are not allowed. If you are an insurance based patient and need to cancel your surgery, you may reschedule once with no penalty. Any subsequent rescheduling will be a $50.00 fee.
If your consultation is strictly cosmetic in nature, there is a $100 charge, which will be deducted from your surgery cost. If during your consultation it becomes an insurance case, it is no longer cosmetic and your copay will be due. To reserve your desired date and time for cosmetic surgery, there is a non-refundable $1,500.00 deposit required. If you are a cosmetic patient and need to reschedule your surgery there is a $250.00 fee. If you are a cosmetic patient and for any reason other than the death of an immediate family member or lack of medical clearance by another MD, you decide to cancel your surgery, there is a minimum 20% penalty in your refund. Please see your cosmetic contract for complete details.
Patient/guarantor credits in amounts less than $20.00 will be retained on account to be credited toward future balances unless a written request for refund is received.
MISSED APPOINTMENTS/LATE CANCELLATIONS
Broken appointments represent a cost to us, to you and to other patients who could have been seen in the time set aside for you. In order to provide excellent care to all of our patients, we require a 48 hour notification if you need to cancel or reschedule; otherwise a $100.00 fee will be incurred for both insurance and cosmetic patients. Excessive abuse of scheduled appointments may result in discharge from the practice.
All Medical Records by Georgia state law Section 2: code section: 31-33-3 states that we can charge a reasonable fee for medical records; our fees are: $0.97 per page for the first 20 pages of the patient's records which are copied, $0.83 per page for pages 21 through 100 and postage & handling charges. Completion of Physician Statements, FMLA, AFLAC, Disability, etc. to be filled out by the staff or doctor will be charged a fee of $25.00.
I have read and understood the Perimeter Plastic Surgery Financial Policy. I agree to assign insurance benefits to the Perimeter Plastic Surgery Practice whenever necessary. I also agree that if it becomes necessary to forward my account to a collection agency, in addition to the amount owed, I will also be responsible for the fee charged by the collection agency for costs of collections.
Signature of Guarantor / Authorized representative: