Aesthetic Gynecology Dallas Patient Registration

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AESTHETIC GYNECOLOGY OF DALLAS
Payment Policy for Aesthetic Gynecology of Dallas

Dr. Thomas is a leading surgeon in his field of expertise and takes great pride providing quality and confidential care. Patients are exceptionally valued and provided extensive consultation time with both Dr. Thomas and his patient liaison, enabling all questions and concerns to be addressed well in advance of scheduled surgery and/ or procedure.

As you can imagine, slots are at a premium. A great deal of thought has been given for evaluation, preparation, and surgery time needed for each procedure. In consideration for Dr. Thomas' time, staff members, and other patients, we have an unwavering financial policy.

A 50% deposit is required at the time of scheduling surgery. This allows us to block the necessary time. The remaining balance is due one week prior to surgery or at the time of your preoperative visit For office procedures, the remaining balance is due at the time of service. All fees must be received by this time. A nonrefundable 25% of deposit will be retained for a cancelled surgery and/or procedure that is not rescheduled with Dr. Thomas. If you reschedule for any reason, your deposit (even if paid in full) will be held as a credit on your account. Dr. Thomas will perform one revision in the office within one year of the original surgery for $500 without IV anesthesia. Dr. Thomas will perform one vaginoplasty revision done at the surgery center within one year of the original surgery. Dr. Thomas will waive his professional fee. However, the patient is responsible for all associated general anesthesia and facility fees. Dr. Thomas is not financially responsible for consultations or revisions performed by other surgeons. Dr. Thomas cannot guarantee sought-after results. Revisions may not accomplish the cosmetic goals you seek.

We accept cash, all major credit cards, money orders, and personal checks. If personal checks are used, all funds must clear the bank 1 week prior to surgery. We provide financing options and would be happy to discuss those with you as well.
Please note, additional surgical procedures cannot be added on the day of surgery unless payment in full has been received.

Sincerely,
Nathan T. Thomas, M.D., FACOG, FAIAVS
Aesthetic Gynecology of Dallas

I agree and understand this payment policy for Aesthetic Surgery and/or Procedures.
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Board Certified in Obstetrics & Gynecology

Medical Information Release Form

(HIPAA Form()
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RELEASE OF INFORMATION*

I authorize the release of information including examinations rendered to me, medical diagnosis and billing information.Information is NOT to be released to anyone.
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You may leave a detailed messagePlease leave a message asking for me to return your callYou may text me to contact the office.
EMERGENCY CONTACT
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This Release of Information will remain in effect until terminated by me in writing.
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Nathan T. Thomas, MD, FACOG

Board Certified in Obstetrics & Gynecology

Patient Financial Responsibility & HIPAA Form

Thank you for choosing Dr. Nathan Thomas for your medical needs. We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.

Patient Financial Responsibilities
- The patient (or patient's guardian, if a minor) is ultimately responsible for the payment for treatment and care.
- We will bill your insurance for you. However, the patient is required to provide the most correct and updated information regarding insurance.
- Patients are responsible for payment of copays, deductibles and all other procedures or treatment not covered by their insurance plan.
- Copays, deductibles and coinsurance charges are due at the time of service.
- Patients may incur, and are responsible for payment of additional charges, if applicable. These charges may include:
- Charge for returned checks - $30.00
By my signature below, I hereby authorize the assignment of financial benefits directly to Dr. Nathan Thomas and any associated healthcare entities for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered by this assignment.

Patient HIPAA Acknowledgement and Authorization
- We respect patient confidentiality and only release personal health information about you in accordance with the State and Federal law. The attached notice describes our policies related to the use of the records of your care and how you may get access to this information. Please review this policy carefully.
- Your signature below signifies your consent to the use and disclosure of your PHI by our office during treatment, billing, reimbursement and medical office operations as outlined in our Notice. You agree and consent that your PHI may be communicated to you via telephone, text messaging, postal service or email (encrypted or unencrypted
By my signature below, I acknowledge that I have received and read the privacy notice provided by Dr. Nathan Thomas. I hereby authorize Dr. Nathan Thomas, staff and hospitals associated with this office to release medical and other information acquired in the course of my examination and/or treatment to the necessary insurance companies, third party payors, and/or other physicians or healthcare entities required to participate in my care.
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Cancellation, Reschedule and No Show Policy

We understand that you may need to cancel an appointment occasionally. In such
circumstances, please contact us no later than 24 hours before your scheduled
appointment time. You may do so by calling 972-566-4555 or using the patient portal. Failure to do so will result in a $50 fee which must be paid prior to rescheduling the missed appointment or scheduling any future appointment. Any appointment that is a No Show will also result in a $50 fee.

We have a 15 minute grace period from your scheduled appointment time. It may be necessary to reschedule your appointment if your arrival time is greater than 15 minutes. We know that unexpected situations sometimes arise. In the case of emergencies or extenuating circumstances, we may waive the no-show fee. Waivers are determined on a case-by-case basis at the practice management's sole discretion.

By signing this form, you are acknowledging the new cancellation, reschedule and no show policy and accepting responsibility.
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