NO SHOW & CANCELLATION POLICY
We are often on a waiting list for appointments. To allow patients on our waiting list appointments, we kindly ask that you give
3 business days (M-F) if canceling or changing an appointment. In the event of less than 3 business days or a “no show,” you
will be charged $100. If you are a New Patient, the Consultation Fee Policy will apply.
PAYMENT FOR COSMETIC PROCEDURES: All in office cosmetic procedures must be paid in full at the time of service.
Surgical procedures must be paid in full before any procedure is performed.
POLICY ON PACKAGE PURCHASES: All packages purchased are to be paid in full at the time of purchase. Packages are
non-refundable. Packages are non-transferable.
SKIN CARE PRODUCT PURCHASES: All returned unopened product boxes will be credited to your account and may be
used toward any services if returned within 30 days of purchase. All opened product sales are final and cannot be refunded.
RETURNED CHECKS: There will be a charge in the amount of $30.00 for any returned check. This policy is strictly
enforced, and future treatments MAY be withheld until NSF checks have cleared the bank.
FINANCIAL ARRANGEMENTS: Our commitment of excellence through our various services is extended to you with regard
to the payment of our services. In order to achieve this goal, definite payment arrangements must be established by your second
visit. All charges quoted pertain only to Dr. Chernoff’s charges additional charges will also be charged to you from outside
sources with all surgery cases.
ALL REFUNDS WILL BE PROCESSED WITHIN 120 DAYS OF APPROVAL.
WAITING ROOM: We strive to provide the best treatment in a relaxing environment, so please make child care arrangements
in advance and mute all cell phones.
PRIVATE INSURANCE COVERAGE: You are responsible for the full amount of our charges. and file directly with your insurance.
You may keep your receipt
NO INSURANCE: Payment in full is expected at each visit. Should you require prolonged treatment; a monthly payment
arrangement can be established. At the conclusion of your treatment, all services are to be paid in full within 60 days.
WORKER’S COMPENSATION: A confirmation, by phone or other means, is required to acknowledge the services as
Worker’s Compensation. If by letter, that letter should include a claim mailing address and the contact person at your place of
employment.
ACCIDENT CASES: Accident cases are considered self-pay and we do not become involved in litigation of the settlement of
these cases except where required by Federal law (Medicare/Medicaid). You will be given a receipt for any payment made to
pursue your claim in these situations.
NO CHALLENGE POLICY: Services that are performed and are paid with a credit card, or financing third party are not
eligible for payment challenges after services are provided. I will not challenge such credit, debit, or financing card payments
once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues
that might arise, which are further addressed in the Revision Policy. I agree that this non-credit card challenge agreement is
irrevocable.
By signing below, I certify that I have read and understand the above stated information. I understand, once again, that I am
responsible for any amount not covered by insurance. I will also be responsible and liable for all collection of attorney fees
incurred while enforcing collection of said amount.