Cosmetic Financial Agreement & Policies

 

INTRODUCTION

Cosmetic services are elective and are not covered by and are not able to be submitted to your health insurance company (this also includes HSA & FSA plans), thus you are considered a “Self-Pay” patient. Self-pay patients will be responsible for necessary charges associated with their service(s) rendered. The fees charged for this service(s) do not include any potential future costs for additional service(s) that is elected to have performed in order to optimize or complete the patient’s desired outcome. Additional costs may occur should complications develop from the service.

Subsequent service(s) that are performed with the intent of revision will also be the patient’s responsibility.

All cosmetic service fees (i.e. Laser, Injectables, CoolSculpting, Skincare Retail products, and MedSpa Services) are due upon the time of treatment. In some cases, a deposit may be requested prior to scheduling specific treatments, and in those cases the remaining balance of that treatment is due prior to services being rendered (i.e. CoolSculpting).

All cosmetic self-pay patients will receive a cosmetic consultation prior to their cosmetic services being rendered. At that time fees, contraindications, pre and post care, side effects, and potential benefits will be reviewed. The provider reserves the right to refuse to perform procedures or treatments which are not appropriate for the patient in his/her professional judgement.

PAYMENT POLICY

 At Anne Arundel Dermatology and Anne Arundel Dermatology Affiliate locations, cosmetic treatments are elective aesthetic procedures, these treatments and procedures cannot be billed to insurance. Payment for all treatments are due at the time of the treatment, and all packages must be paid in full prior to the first treatment being rendered. We do not offer financing or payment plans. For our patients’ convenience, we do participate with all of *CareCredit’s promotional plan options for purchases $200 and over. All treatments are final sale; there are no refunds or

credit issued for any service, including, but not limited to; Laser treatment, IPL, Botox, Fillers, Microneedling, Microdermabrasion, Chemical Peels, Facials, Body Sculpting, CoolSculpting, and Skincare Retail products. We accept Cash, Personal checks, Visa, MasterCard, Discover, American Express, and *CareCredit. There will be a $25 service charge for each returned check.

When CareCredit is used to pay for cosmetic procedures; the following guidelines must be adhered to in order to process the patient transaction(s). The patient will need 2 forms of valid identification: One primary and One secondary. An Anne Arundel Dermatology or Anne Arundel Dermatology Affiliate employee must notate both valid ID types in the space provided in the shaded top portion of the CareCredit application. If the patient submitted the application online, an Anne Arundel Dermatology or Anne Arundel Dermatology Affiliate employee must notate the ID types on the signed printout of the online application. The employee must retain the signed application page (for 72 months), whether the application is Approved or Declined.

 ID Requirements for Terminal Transactions, a Card must be Present and Swiped. When swiping the CareCredit Private Label Card or Rewards Mastercard to process a transaction, the card serves as the primary identification, and additional ID does not need to be notated. If Card is Present, but cannot be swiped then 1) Check one form of Primary ID from

the approved list and 2) Verify name on ID matches the name shown on the card then 3) Capture ID information on the bottom of the receipt. If the card is not Present/Available Call CareCredit Provider Services at 800-859-9975 and verify names on the account and the available credit.

 -Transaction Restrictions –

  • CareCredit can only be used and charged for services that have been completed or that will be completed within 30 days of the initial This requirement does not apply to charges for orthodontic service or for custom products ordered by the patient/client.
  • Accounts Receivable balances aged greater than 90 days may not be charged on CareCredit credit
  • A NO REFUND policy, where no services/products were rendered, is not acceptable, except in the case of custom special order items, where the non-refund-ability has been clearly disclosed to the
  • Any refunds processed for cardholders who originated a transaction with a CareCredit credit card must be refunded to the CareCredit credit
  • As an important reminder about the CareCredit credit card, Anne Arundel Dermatology and Anne Arundel

Dermatology Affiliate locations cannot pass on the merchant and/or any other CareCredit fees to your patients/clients. This aligns with CareCredit Card Acceptance Agreement for Participating Professionals.

  • If a cardholder desires to transact using their CareCredit credit card, the card must be accepted regardless of the transaction amount. For example: a) Transactions under $200 will be processed as Standard Account Terms
  1. b) Transactions of $200 or more will be processed on at least the 6 month Deferred Interest/No Interest if Paid in Full
  • Consumers (regardless of channel (e.g. in-store, online, by phone) must be provided a copy of the sales

At most but not all, Anne Arundel Dermatology and Anne Arundel Dermatology Affiliate cosmetic offices, we participate in loyalty rewards programs such as Brilliant Distinctions through Allergan and Aspire Rewards through Galderma. We believe this is just another layer of customer services and patient appreciation that we can extend to you during your visit! When you purchase Botox, Juvaderm, Latisse, Restylane, Dysport, or CoolSculpting for example, and you are a participant with the loyalty rewards programs you can receive loyalty points which will accrue over time. The points may then be applied to

future cosmetic procedures as outlined by the Vendor and AADerm parameters, in addition to any office discounts, events, or promotions being offered at the point of purchase. This is the only instance in which 2 promotional/discount opportunities can be combined. There are no further exceptions. The use of points and/or redemption can only be applied when a treatment

is paid in full at the time of your service being rendered. We are only able to honor and redeem loyalty points, coupons, and discounts when the patient’s unique Vendor code has been provided to an Anne Arundel Dermatology or Anne Arundel Dermatology Affiliate employee at the point of sale.  Loyalty coupons, and discount redemptions will not be redeemed retroactively. Loyalty coupons, and discount redemptions will not be redeemed by supplying proof of email notification, but only after supplying your unique Vendor code. The Brilliant Distinctions and Aspire Rewards points are non-refundable.

The reward points will expire and we strongly encourage our patients to keep track of your points through either the Brilliant Distinctions App or Aspire Rewards website. When points are applied to a cosmetic treatment transaction, any office discounts, event pricing, and/or promotions will first be applied, then the rewards points will be applied secondarily; example:

$300 for specified treatment, 10% off for Veteran’s discount =  $270 Balance, you are redeeming $50 BD points, so your balance owed is now $220.

All skincare retail product (both RX and non-RX) sales are final and monies paid are non-refundable. In case of documented allergic reaction or clearly defective product, exchanges can be made within 14 days of purchase for skin care product credit only. Must have original proof of purchase and exchange can only be made at original purchase location, per management approval.

*CareCredit is offered at select locations.  Please check with your office location and with your provider at the time of consultation, and prior to services being rendered to confirm their participation with this payment option.

*Allergan Brilliant Distinctions and Galderma Aspire Rewards participation is offered at select locations. Please check with your office location and with your provider at the time of consultation, and prior to services being rendered to confirm their participation with this payment option.

-You will not receive a coded receipt for the service(s) rendered. Your check, or credit card slip is your receipt. If cash is paid, a cash receipt will be provided.

-The office will at no time, now or in the future, submit a claim to your insurance carrier, as the provider has deemed the service not medically necessary under the terms of this practice’s contract with your carrier.

CANCELLATION AND NO-SHOW POLICY

 As a courtesy to other patients, we request you arrive on time. If you to arrive more than 10 minutes late for your scheduled appointment, you may be asked to reschedule. Appointments canceled on the date of a scheduled visit represent a cost to the practice and a missed opportunity to see other patients who are waiting for a visit date.

-We require 24 hours’ notice of cancellation. After three missed appointments, you will be charged a fee of $50.

-Reminders will be provided but are not guaranteed.

-The $50.00 fee will need to be paid in full prior to rescheduling your next appointment, and/or prior to being seen for treatment should your account have an outstanding balance.

-If you are a new patient, we ask that you arrive 30 minutes early for registration completion, so we can see you at your scheduled appointment time.

-A minimum of 24 hours’ notice is required to cancel an appointment without incurring a cancellation fee of $50.00. The fee is not covered by your insurance plan. There is a separate CoolSculpting/Body Sculpting cancellation policy that governs CoolSculpting/Body Sculpting rescheduling.

COOLSCULPTING/BODY SCULPTING POLICY; DEPOSIT, REFUND POLICY & TREATMENT OUTCOMES POLICY

 -A $500.00 deposit is required to secure your CoolSculpting/Body Sculpting appointment date and time with your treating provider. The remaining CoolSculpting/Body Sculpting balance will be due the day of your appointment prior to receiving your treatment. The $500.00 deposit gets applied to your remaining balance due, and the deposit serves as a reservation for the appropriate time needed to treat based on your consultation expectations.

-50% of your deposit ($250.00) is non-refundable if you miss your CoolSculpting treatment appointment or fail to provide at minimum 24 hours’ notice to cancel the appointment to treat. (This fee goes towards Provider and Administrative costs associated with treatment schedule).

-Should you wish to reschedule your treatment, an additional pre-paid deposit of $250.00 will be required, and you must receive treatment within 90 days of your original, canceled treatment date. The additional $250.00 deposit gets applied to your remaining balance due.

-Any monies paid for CoolSculpting/Body Sculpting packages are non-refundable. If your provider decides it best not to complete your treatment package, it may be established that monies for unused cycles will remain on your account as a credit towards other services. *This determination will be made as needed and based on Office Manager’s approval at the purchasing location. This is not a guarantee.

-In the event that a package or series of treatments has begun, these services will be considered to have been rendered even though the full series may not have been completed.

– We do not offer refunds on services rendered.

GIFT CERTIFICATE AND GIFT CARD POLICY

 Gift certificates and gift cards purchased either at Anne Arundel Dermatology locations, Anne Arundel Dermatology Affiliate locations, as well as online are non-refundable. Gift certificates and gift cards cannot be redeemed for cash, and they cannot be redeemed for gratuities.

Gift cards are valid for four years after the date of purchase and AADerm will not impose fees or charges of any kind during that four-year period. Federal legislation stretches expiration protection to five years; however, consumers may be charged fees during this fifth year and any year thereafter.

Any terms or conditions concerning an expiration date or fee will be printed clearly in a visible place on the front or back of the certificate/card, on a sticker permanently affixed to the gift certificate/card, or on an envelope containing the gift certificate/card. Expiration date will be noted on the sticker or packaging. Typical fees include service charges, fees for inactivity, maintenance fees, and reload fees. Terms and conditions will not be charged after the issue of the gift certificate or gift card unless they benefit the cardholder.

PRE-PAID TREATMENT, TREATMENT PACKAGE/SERIES POLICY; REFUND POLICY & TREATMENT OUTCOMES POLICY

 To deliver the best level of patient care and efficiency regarding packages and series offerings we strive for transparency and for clear expectations to be set with the policies below:

-All service packages and pre-paid treatments must be used within 2 year(s) from the date of purchase or they will expire.

-In the event that a package or series of treatments has begun, these services will be considered to have been rendered even though the full series may not have been completed.

  • We do not offer refunds on services

-At AADerm we offer treatments and product that are irrevocable. Therefore, we do not issue refunds or credits for any product or service that has been injected or used in your treatment including by not limited to (Botox, Juvederm, Kybella, Dysport, Restylane, and Jeuveau). Again, all sales are final.  In consenting to be treated, it is important that our patients understand and accept this condition.

-Should you wish to discontinue your treatment in the midst of a series, credit for the pro-rated share of unused treatments at the discounted package price may be extended, and this may be used to purchase other treatments or products offered by AADerm. *This determination will be made as needed and based on Office Manager’s approval at the purchasing location. This is not a guarantee. 

  • Patients who have purchased our services from a Friends & Family event or Open House, agree that they understand and consent to the terms and conditions of that promotion, as the terms and conditions of that promotion will apply. Services that have already been rendered will not be redeemed

NEW PATIENT/WALK-IN PURCHASE POLICY

 All New Patient paperwork must be completed, and a patient chart entered into our secure and HIPPA compliant EMR and practice management system before a transaction or purchase can be made. This may also require associated consent forms signed and reviewed by an Anne Arundel Dermatology or Anne Arundel Dermatology Affiliate provider. No exceptions will be made.

ONLINE STORE PURCHASES

 All policies and criteria outlined in this agreement are applicable to any online store purchases made through either Anne Arundel Dermatology or Anne Arundel Dermatology Affiliate locations.

TREATMENT OUTCOMES

 At Anne Arundel Dermatology and Anne Arundel Dermatology Affiliate locations we take great efforts to be honest in all of the interactions with you as our valued patient. Aesthetics is not an exact science, and patient outcomes vary from patient to patient, and results are based solely on your individual response to the treatment(s). As it is not possible to predict or guarantee results, any payments made are for treatments performed, not for the specific result desired.

*ADDITIONAL SITE SPECIFIC CONSIDERATIONS (HUNT VALLEY, MD)

 -50% Deposit is due upon scheduling your appointment. The balance will be due on date of service, prior to treatment.

-Ulthera/Thermage: 20% of the total fee is nonrefundable if the appointment is canceled with less than ONE WEEK of notice.

-Sculptra: Full deposit is required. Nonrefundable if the appointment is canceled with less than ONE WEEK of notice.

-Other procedures: 20% of the total fee is nonrefundable if the appointment is canceled with less ONE WEEK of notice.

*Additional site locations and/or offices may have additional considerations or policies that may not be indicated by this form. Please ask your site location if there are any of these instances.

Consent: My consent for the procedure(s) is strictly voluntary. My signature on this form authorizes Anne Arundel Dermatology to perform the procedure(s). I have read this informed consent form and certify that I understand the contents in full. My signature indicates that I am consenting to receive treatment(s) and have had the opportunity to ask questions about the procedure(s) and associated risk(s). I have been advised of the risks involved in such treatment(s) and alternative treatment(s), including no treatment at all. I recognize that the practice of medicine is not an exact science and acknowledge that no guarantees or assurance have been made to me concerning the results of such procedure(s). I certify that I am a competent adult of at least 18 years of age and am not under the influence of alcohol or drugs. I understand the financial policy outlined

in this form associated with elected Cosmetic treatment(s), and I agree to abide by the policy outlined and explained in detail above.

Patient Printed Name & Signature:  

Date:  ___

Physician Printed Name & Signature:  _________________________________________________________

Treating Provider Printed Name & Signature:  ___________________________________________________

Witness Printed Name & Signature:  ___________________________________________________________