Plastic Surgery Financial Policy and Payment Agreement

Patient Information

Name: _________________________ Date: _____________ Date of Birth: __________________ Account #: _________

Financial Policy Terms

1. Payment Responsibility

• I understand that I am financially responsible for all charges, whether covered by insurance or not
• Full payment for cosmetic procedures is required 2 weeks prior to the scheduled surgery date
• A non-refundable deposit of $_____ is required to schedule surgery

2. Insurance and Coverage

• I understand that while the practice may participate with my insurance carrier, I am responsible for:
  • Verifying specific plastic surgery benefits
  • Obtaining necessary pre-authorizations
  • Meeting all deductible requirements
  • Paying all co-payments and co-insurance
• Insurance co-payments are due at the time of service

3. Payment Methods

• We accept: Cash, Check, Visa, MasterCard, American Express, Care Credit
• Returned checks will incur a $35.00 fee
• Payment plans must be arranged prior to surgery

4. Cancellation Policy

• Surgeries cancelled less than 14 days before the scheduled date forfeit 50% of the surgical fee
• Missed appointments without 24-hour notice will incur a $50 fee

5. Additional Fees

• Post-operative visits within 90 days are included in surgical fees
• Additional procedures or revisions will be charged separately
• Medical records requests: $25 processing fee

Acknowledgment

I have read and understand this financial policy. I agree to be bound by its terms.

Signature: _________________________ Date: _____________

Print Name: ________________________

© [Practice Name] | Updated [Date]