Private Pay: payment for all services provided is due and payable at the time of service. If paying by check, there will be a $50 charge for all checks returned for insufficient funds. Intial:   Initials*   

Copies of Medical Records are subject to a $25 fee. Intial:   Intials*   

HMO/PPO’s: (Such as Aetna US Healthcare, Cigna Healthcare, etc.) You are expected to pay the co-payment defined by your plan upon arrival at the office. You are also responsible for payment of any deductible amounts and non-covered services upon exit. You will be billed for any amount due after insurance has paid. Prompt payment is then expected. Also, there may be a separate charge to an outside laboratory that you will be responsible for as well. Intial:   Initials*  

Cancellation Policy: If you are unable to keep an appointment, we ask that you kindly provide us with AT LEAST 24 HOUR NOTICE. There is $100 cancellation fee for all providers, including aestheticians and brow technician. Intial:   Initials*  

Medicare: You are responsible for 20% of Medicare’s approved amount unless you provide our office with secondary insurance coverage at the time of service.

MEDIGAP/CROSSOVER Plans: If you are covered by Medicare and you have a Medigap policy or are covered by a plan to which Medicare automatically crosses over the claim, you are responsible only for any unpaid deductibles you may have not yet paid.

WE ACCEPT MOST MAJOR CREDIT CARDS FOR YOUR CONVENIENCE

I have read, and I understand my financial obligation to Bella Skin Institute, and I agree to abide by the terms stated above. Signature of Patient or Legal Guardian:   Signature*   Date:   Date*   Relationship:   Relationship 

PRIVACY NOTICE: I have reviewed a copy of the Privacy Rules from Bella Skin Institute. Signature of Patient or Legal Guardian:   Signature*   Date:   Date*   Relationship:   Relationship   

MEDICARE
I hereby authorize any provider of services to me who files a claim to Medicare Program, it’s intermediaries or carrier and to Medigap and any plan to which Medicare crossover to release medical or other information about me that is required for the adjudication of a claim submitted for care provided to me. I also assign payment of any health benefits due me to the party who files an assigned claim to the Medicare program for services provided to me. This authorization is for my lifetime unless revoked in writing by me or my legal guardian or assign. Signature of Patient or Legal Guardian:   Signature*   Date:   Date*   Relationship:   Relationship