Office Policies
Thank you for choosing us as your healthcare provider. Our doctors and staff members aim to provide the best professional advice, care, and treatment obtainable. The following is a statement of our office policies which we require you to read and sign prior to any treatment. Additionally, a copy of our Notice of Privacy Practices (HIPPA Regulations) is available to you, upon request.
APPOINTMENT RESERVATION FEE, CANCELLATION/RESCHEDULE POLICY & LATE POLICY
As one can imagine, last minute cancellations or reschedules and late or no shows are very disruptive to our practice. As a result, we have the following policies: we charge a $100 reservation fee for consultations and treatments, which may be applied as credit to a future service or product; an additional $50 fee, which cannot be used as credit, will be assessed to any patient who cancels or reschedules within 2 days of their scheduled appointment OR who require rescheduling because they are more than 15 minutes late to an appointment.
INSURANCE PLANS AND PAYMENT POLICIES
Visage does not participate with medical insurance plans. You will be responsible for full payment prior to or at the time of service. We accept cash, checks, MasterCard, Visa, Discover, Amex, and CareCredit. Checks returned for non-sufficient funds will be charged a fee of $25.00. We do not re-deposit an NSF check a second time. Balances must be handled by cash, credit card or money order.
PROOF OF IDENTITY
We are now required to have proof of your identity on file. We require a photo ID such as a Driver’s License, work ID badge, etc. This will be copied into your private medical records only to prove who we are treating. We understand that some people are reluctant to having their ID scanned. If this is the case, we may have to ask to view your photo ID at each visit.
EMAIL COMMUNICATION
Email is a convenient means of communicating, but it is not as secure as telephone. The HIPPA Privacy Rule does not prohibit the use of unencrypted e-mail for treatment-related communications between us and you, but every effort will be made to limit the amount or type of information disclosed through the unencrypted e-mail. We will respond to e-mails within 72 hours of receiving them. We do not use e-mail for emergencies or for situations needing immediate or urgent attention. All e-mails to and from you are included in your medical record(s). At any time, you have the right under the HIPAA Privacy Rule to request and receive medical messages via alternative means. There is a section on the new patient intake form where you may indicate if you are agreeable to email message.
CONSENT AND RELEASE OF DIGITAL MEDIA & DIGITAL MORPHING
I hereby authorize the providers at Viságe Facial Plastic Surgery, SC, aided by such assistants, photographers, or technicians to take digital photographs of me for the purposes of this consultation and for general medical documentation. If pursuing elective surgery, I further grant these providers permission to digitally morph my image to aid me in my decision. I relinquish all right, title, and interest in these images to Viságe Facial Plastic Surgery, SC and its providers. I may revoke this consent in writing, delivered to Viságe Facial Plastic Surgery, SC. Such revocation shall therefore be effective as to any further use not already committed to by these providers. This consent is in consideration of services performed and consultations conducted or to be performed or conducted by the providers at Viságe Facial Plastic Surgery, SC. There have been no representations or inducements concerning this consent, except as set forth herein.
AGREEMENT CONCERNING ELECTRONIC IMAGING
During consultation, I may have been shown or may be shown pictures on an electronic imaging device. I understand that those pictures and alterations of those pictures are solely for the purposes of illustration and discussion. I understand that the outcome of the procedure is directly related to individual characteristics. I understand that because of the significant differences in how living tissue reacts to surgery, there may be no relationship between the electronic images and final surgical results.
I understand that I may request a Notice of Privacy Practices (HIPPA Regulations) prior to or during any service being provided to me by the Practice. I understand that unless I provide the Practice a written list that expressly states restrictions to the use and/or disclosure of my medical information, I consent to the policies outlined herein or within the Notice of Privacy Practices. I have read this document and agree that a photocopy of it shall be considered as effective and valid as the original.
