Beauty Patient Financial Responsibility
? Please provide the receptionist with your current and active billing information prior to your appointments, i.e. address, email, credit card information
? Contact your insurance company and be familiar with your plan, i.e:
o Is cosmetic dermatology covered on my plan?
? These are elective procedures, generally they are not covered
o Do I have a health care savings account (HSA), if so can I use it to pay for cosmetic procedures like botox or dermal fillers?
o Will my visits be covered, or will they be subject to deductible?
o What is a deductible and how much is mine?
? Consultations are free of charge.
? Payments for your aesthetic treatments are collected in full at the time services are rendered and cannot be waived for any reason. We do not bill medical insurances for services performed at Home Towne Beauty.
? If your billing information is set to change or term, you must notify the office before the next payment is due.
I have read and understand the patient responsibilities regarding my medical insurance as presented by HOME TOWNE BEAUTY. By signing this form, I will provide active billing information. I am responsible for any balances. This includes in network provider charges, deductibles, co-payments, co-insurance, out of network provider charges, and non-covered services rendered at HOME TOWNE BEAUTY. I accept full responsibility of billing charges.
By entering your name above in text, you are acknowledging this as your electronic signature.