3D Areola/Nipple Tattooing Predetermination

3D Areola/Nipple Tattoo Predetermination

PLEASE READ: Reimbursement for 3D areola/nipple tattooing through your insurance provider is common, though not guaranteed. To improve your chances of reimbursement, we encourage you to request a predetermination of benefits from your insurer prior to your appointment. This digital form will generate two PDFs to support your predetermination request: a template letter of medical necessity for your physician’s signature and a predetermination of benefits request letter. These documents will be sent directly to your email. We are not in-network with any health insurance providers and do not bill or communicate with insurance companies on your behalf. Full payment is due at the time of service. After your appointment, we will provide a superbill (detailed invoice) that you may submit to your insurance provider for potential reimbursement.
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Unilateral Nipple/Areola TattooBilateral Nipple/Areola Tattoo
Which location will you visit for your 3D nipple/areola tattoo?*

Brighton, MIEvans, GA
Payment Policy: Full payment of is required at the time of service. We do not bill insurance directly. Instead, we provide a superbill (medical invoice) that you may submit to your insurance company for possible reimbursement. Any reimbursement will be sent directly to you from your insurer.

Acknowledgement: I understand that payment is due at the time of service. I understand that insurance reimbursement, if available, will be sent directly to me and is not guaranteed.

Email Communication Consent: I understand that email is not a secure form of communication and may carry some risk of unauthorized access. By signing/submitting this form, I consent to the use of email by Kendra Neal Studio, LLC to send and receive my information, including protected health information (PHI), for scheduling, billing, and insurance purposes. I may withdraw this consent at any time by notifying the studio in writing.
By signing below, I acknowledge and agree to the payment, insurance, and communication policies stated above.
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3D Areola/Nipple Tattoo Predetermination