Patient Name:<<Patient_FirstName>> <<Patient_LastName>>

Today's Date:<<Current_DateTime>>

Date of Birth:<<Patient_Birthdate>>

Provider:<<Provider_FirstName>> <<Provider_LastName>> <<Provider_Degree>>

Procedure:

Facility:

Date of Procedure:

Amount of Procedure:

 

 

AGREEMENT FOR SURGERY SCHEDULING AND CANCELLATION

 

 

This Agreement for Surgery Scheduling and Cancellation (Agreement) is entered into between the above named patient (“Patient”) and Boonipat Craniofacial and Facial Plastic Surgery, PLLC d/b/a FacePlus Plastic Surgery Institute (FacePlus).

 

Patient has established a physician – patient relationship with FacePlus and desires to schedule the above referenced surgical procedure at the above referenced facility. Patient and FacePlus agree to the following:

 

1. Payment Terms

The total fee for the elective procedure must be paid in full at least ten (10) days before the scheduled surgery date. Surgery will not be confirmed until full payment is received.

 

2. Accepted Payment Methods

Cash, Personal Checks, and all major credit or debit cards are accepted. Approved third-party financial options may also be available based on the approval of the third-party. A convenience fee for use of credit or debit cards may apply.

 

 

3. Refund Policy

All payments made towards the surgery are subject to the cancellation terms outlined in this Agreement. No refunds will be processed outside the scope of this policy.

 

4. Facility Financial Agreements

Patient is responsible for making separate financial arrangements with the surgical facility where the procedure will be performed. This includes any facility fees, anesthesia costs, or additional services not covered by the surgical fee paid to FacePlus. It is the Patient’s responsibility to coordinate these payments directly with the above referenced facility in accordance with their policies and timelines. FacePlus and/or our surgeons, staff, and/or contractors are not a representative of or employee of the facility, unless otherwise noted. FacePlus is not a party to or subject to any facility financial agreement.

 

5. Non-Refundable Deposit

A non-refundable deposit of $1,000 is required to secure the surgery date. This deposit will be applied toward to the total cost of the procedure. If the surgery is canceled by the Patient for any reason, including inability to secure a facility financial agreement, the deposit will not be refunded.

 

6. Cancellation Policy

Patient-Initiated Cancellation

· More than 3 weeks prior to surgery date: The patient forfeits the non-refundable deposit.

· Less than 3 weeks but more than 48 hours prior: The patient forfeits the non-refundable deposit and 50% of the surgeon’s fees.

· Within 48 hours of surgery: The patient forfeits 100% of the total surgeon fee.

 

Practice-Initiated Cancellation

If FacePlus cancels the surgery for any reason NOT related to medial safety or patient non-compliance, the Patient will be entitled to a full refund of all fees paid, including the non-refundable deposit.

 

Medical Cancellations

If the surgery must be postponed or canceled due to medical reasons, as determined by the Surgeon or anesthesiologist, the non-refundable deposit will be retained, but all other fees paid will be held as a credit for future surgery within six (6) months. Rescheduling fees will be waived in this case.

 

Patient will be drug tested for Amphetamine, Secobarbital, Buprenorphine, Oxazepam, Cocaine, Methylenedioxymet hamphetamine, Methamphetamine, Methadone, Morphine, Oxycodone, Phencyclidine, Propoxyphene, Nortriptyline, and Cannabinoids (THC) prior to procedure. If test comes back positive for drugs not prescribed by provider and not specifically discussed by patient and provider, patient will forfeits ALL fees that have been paid and will NOT have the opportunity to reschedule.

 

7. Rescheduling Policy

Patient-Initiated Rescheduling

If Patient wishes to reschedule the surgery, a $500 rescheduling fee will be charged.

 

Medical Rescheduling

If surgery is postponed due to valid medical issues with supporting letter from the patient's primary care or other qualified medical providers, no rescheduling fee will be charged, provided Patient reschedules within six (6) months.

 

8. Patient Obligations

Medical Clearance and Pre-Operative Compliance

The Patient agrees to complete all required pre-operative assessments and obtain medical clearance as necessary. Failure to comply with pre-operative instructions may result in cancellation of surgery without refund.

 

LABS: All labs will need to be ordered by patients PCP as they will be responsible for addressing any abnormal results. If our facility orders blood work a $50 fee will be charged, and the patient will still be required to notify their primary care provider to address and treat any abnormal lab results. Our clinic ( FacePlus Plastic Surgery Institute) shall not be responsible for any surgical complications/health issues that may arises from failure to address any of the patient's medical issues.

 

Disclosure of Health Information

The Patient agrees to provide complete and accurate medical history and disclose any changes in health status before the surgery. The Practice reserves the right to cancel or postpone surgery if undisclosed medical conditions are identified. No refund will be provided.

 

HIPAA Compliance and Information Disclosure

FacePlus will comply with all HIPAA regulations. In the event of a financial dispute or collection efforts, the Patient consents to the disclosure of necessary information related to payment and scheduling to resolve the issue. This disclosure will be limited to relevant parties such as billing agencies or financial institutions.

 

9. Financing Agreements

If the Patient elects to finance the procedure through an approved third-party financing company, the Patient is responsible for ensuring all financing documentation is completed and submitted prior to the Pre-Op appointment.

 

Patient is responsible for fulfilling the terms of the financing agreement regardless of changes in surgery scheduling. Any changes to the surgery date or cancellation do not alter the Patient’s obligation to the financing company

 

10.Insurance

If patient is using insurance, patient is responsible for updating all insurance cards and will be charged a fee of $200 to verify eligibility and benefits. The fees must be received prior to us working on any verification.

 

11.Completion of Forms

Patient is responsible for bringing in any forms that need to be filled out for employers as well as pay any fees that may apply.

FMLA paperwork will need 5-7 business days to be completed and a fee of $100.

First doctor's note will be free of charge. Subsequent doctors notes will have a $25 charge for each additional note.

Copies of medical records will be 3- 5 business day turnaround with a fee schedule:

Paper:
No more than $25.00 for the first 20 pages; then,

$0.50 per page for every copy thereafter

In addition, actual cost of mailing or shipping

Also, a reasonable fee not to exceed $15.00 for executing affidavit.

Electronic:

$25.00 for 500 pages or less

$50 for more than 500 pages

 

10. Governing Law and Venue

This Agreement shall be governed by and construed in accordance with the laws of the State of Texas. Any disputes arising out of or related to this Agreement shall be brought exclusively in the state of federal courts located in Lubbock County, Texas, and Patient expressly consents to this jurisdiction.

 

This Agreement is executed on the date indicated above by the parties:

 

 

<<Patient_FirstName>> <<Patient_LastName>>
<<Current_Date>>

 

FACE PLUS PLASTIC SURGERY INSTITUTE

By: <<User_FirstName>> <<User_LastName>>

Signature: 
<<Current_Date>>