The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as a patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov
We have adopted the following policies:
DO NOT BRING SOMEONE THAT YOU DO NOT WANT INFORMATION RELEASED TO.
Dr. Athre will not allow you to be discharged to a taxi service. If you have no relatives or friends that satisfy the above requirements, you can choose to be discharged to a service such as Cameo Caregivers. Again, your healthcare will be discussed with your caregiver to ensure that postoperative care is given to you appropriately. These services are HIPAA compliant and cannot release your information.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
Medical Records Policy
You may request an unofficial copy of your medical records. These medical records will be printed and MAILED to your official address on file. If you request a copy of your medical records, please allot at least 14 business days to process your request and mail your records.
Requests of your photographs may also be requested. A printout of all photographs will cost $50. If you would like your photographs in digital format, please request photos in digital format. The cost will be $50 and will be mailed to you on a USB drive.
In order to book the date of your procedure, a deposit is required to be paid. For procedures under $5000, the deposit is $1000. For procedures greater than $5000, the deposit is $2000.
The deposit is required to secure the date of surgery. Surgery cannot be scheduled without your deposit. Acceptable forms of payment include cash, cashier checks, and credit cards. Patient finance plans with affordable monthly payments are also available. Payment of deposit is ONLY accepted by credit card, cashier’s check, or cash. Deposit payment is not allowed to be paid on a finance plan. Payments are accepted by phone, email invoice or in person. Total payment is due BEFORE your pre-operative appointment. Deposit is NONREFUNDABLE without exception.
All surgical fees are due 21 days (3 weeks) prior to surgery.
If you schedule your surgical procedure less than 3 weeks (21 days) before the actual date of surgery, the full amount of the surgery fees will be required to pay at the time of scheduling.
If you decide to move your surgery to a different date and 2 weeks (14 days) advance notice is given, the entire amount will be applied towards the new date. If less than 2 weeks (14 days) notice is given, 50% of the surgical fees will be assessed as a penalty. We understand that extenuating circumstances come up; and hence, you will be allowed to reschedule your surgery once. If you reschedule your surgery a second time, your surgery will be cancelled and all funds paid will be forfeited.
Once your preoperative appointment is completed, and your invoice is completed, your surgery is NOT CANCELLABLE.
Any refunds awarded will be subject to processing fees. If credit card was used for payment, a 10% processing charge will be deducted from the refunded fees. If check or cash was used for payment, a $100 service charge will be deducted from the refunded fees. If financing company was used for payment, a 10% processing charge will be deducted from the refunded fees.
Your cosmetic quotation includes all post-operative care visits. If a touch-up procedure is required, the surgical portion of the touch-up will be discussed with you. Depending on the circumstances, the surgical fee may be offered for free or for a discount. YOU WILL BE RESPONSIBLE FOR ANY ANESTHESIA AND FACILITY ROOM FEES.
If your procedure requires the services of an anesthesiologist or needs to be done in an outpatient surgery center, you will receive a line-item expense for anesthesia and facility fee in your quotation. This fee is due to the outpatient surgical facility and IS AN ESTIMATE.
The facility and anesthesia fees are to be paid as directed by the surgical facility. Surgeon’s pricing will expire 90 days from the date of the original surgical cost analysis. Facility and anesthesia pricing expires 30 days from the date pricing is given. Refunds to a credit card will have a 10% processing fee on charges.
As a courtesy, Athré Facial Plastics can take care of your anesthesia and facility room fees. The anesthesia and facility room fees are still a separate entity, and you will be entitled to any refunds and will be responsible for any overages. The advantage of this system is that you can make one payment at Athré Facial Plastics rather than make another payment at the hospital facility. To take advantage of this, an administrative fee will be assessed. This fee cannot be financed and will need to be paid via cash, check or credit card.
Raghu Athré, MD PA and Athré Facial Plastics does not accept third party insurance payments, nor does Dr. Athré file insurance claims.
You are free to file your own insurance claim if you choose to do so. Dr. Athré will provide you with your notes, initial consultation notes, operating room notes, operative dictation, and any pertinent photos/media.
YOU are responsible for:
Dr. Athré is NOT responsible for:
Upon paying your surgical balance at Athré Facial Plastics and achieving a (0 – zero) balance, we consider your account complete, and we will not balance bill you for any services. If your case needs a pathologic specimen analyzed, your specimen will be sent to a board-certified pathologist for analysis. The approximate cash pay price for pathology is $250. However, you may consider filing insurance for your pathology. Again, this is your responsibility and questions regarding billing should be addressed to the pathology service provider.
If your case involves general anesthesia, you will get an ESTIMATE for services at the hospital. Any questions with respect to services rendered at the hospital should be addressed with the hospital directly. Dr. Athré has NO FINANCIAL RELATIONSHIPS WITH the hospital and cannot undo charges, etc.
Your procedure will require prescriptions medications such as antibiotics and pain medications. The medications that are prescribed are generic medications, and care has been taken to be as cost-conscious as possible. These medications ARE NOT INCLUDED in your estimate. On our last analysis using GOOD RX, etc. the combined cost of all medications is less than $50. Dr. Athré and his office has no way of knowing whether your medications will be covered under your insurance plan. Furthermore, IT IS NOT THE RESPONSIBILITY of the office to obtain preauthorizations for prescription medications. Medications such as injectable anesthesia medications ARE included in the cost of your surgery.
The following letter details our office policies with respect to financing procedures.
Cases that are scheduled in holiday periods such as summer break, etc will have the terms “HOLIDAY SURGERY” on the quotation. Cases scheduled with less than 14 business days from date of scheduling and the date of surgery will have the term “QUICK SURGERY” on the quotation. In such cases, the entire surgical fee is due in order to schedule the surgery. In both cases, the surgery is non-cancellable, and nonrefundable after monies are paid and the invoice is complete. Any changes in date of surgery will incur a $1000 administrative fee.
Athré Facial Plastics uses text and email to communicate with our patients. We will text you reminders to your appointments. Furthermore, you will be automatically enrolled into our system for emailing and texting patients. Message and data rates may apply. You may stop at any time by replying with STOP to the appointment reminder message.
We appreciate all of our patients and we recognize that it can be difficult to schedule appointments on short notice. In order to be respectful to all of our patients, we have adopted the following policies with respect to rescheduling appointments and no-show’s.
Patients will be afforded a 15 minute grace period to their appointment time. If you are more than 15 minutes late to your appointment, your appointment will be scheduled and you will be charged a $150 no show fee. This fee may be charged to your credit card on file or may be a balance on your account that will need to be paid prior to scheduling additional appointments.
If you need to reschedule your appointment, please do so at least 48 hours (2 days) prior to your appointment. Rescheduled appointments with less than 2 days notice will also be charged the $150 administrative cancellation fee as described above.
Cancellations/rescheduled appointments due to medical reasons will be exempt from administrative charges with appropriate documentation from your healthcare provider.
Website Photography Disclaimer: Photography subjects on this website are professional models, and are not patients of Athré Facial Plastics, unless otherwise stated.