Informed Consent 

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Financial Responsibility/Credit card release 

The cost of surgery/procedures involves several charges for the services provided. The total includes fees charged by your surgeon, the cost of surgical supplies, anesthesia, laboratory tests, and possible outpatient hospital charges, depending on where the surgery is performed. Depending on whether the cost of surgery is covered by an insurance plan, you will be responsible for necessary co-payments, deductibles, and charges not covered. The fees charged for this procedure do not include any potential future costs for additional procedures that you elect to have or require in order to revise, optimize, or complete your outcome. Additional costs may occur should complications develop from the surgery/procedure/procedures. Secondary surgery or hospital day-surgery charges involved with revision surgery will also be your responsibility. In signing the consent for this surgery/procedure, you acknowledge that you have been informed about its risk and 

consequences and accept responsibility for the clinical decisions that were made along with the financial costs of all future treatments. 

I understand that with cosmetic surgery, I am responsible for the surgical fees quoted to me, as well as additional fees for anesthesia, facility (OR), and possibly laboratory, X-ray, and pathology fees. Surgicenters, Outpatient Centers and Hospitals often have rules that certain tissue /implants removed during surgery must be sent for evaluation that may result in additional fees. Please check with your surgeon for approximate additional costs you will be responsible for. 

I understand that there will be a non-refundable fee for booking and scheduling this surgery of 

dollars, which is a part of the overall surgical 

fee. 

Should you cancel your surgery without an approved medically acceptable reason, submitted in writing and acceptable 

to the practice, within weeks of your scheduled surgery, this fee is forfeited. While this may appear to be a charge for services which were not provided, this fee is necessary to reserve time in the OR and in the practice, which are done when you schedule. 

I understand and unconditionally and irrevocably accept the financial responsibilities as outlined above. 

(only for cosmetic cases) COSMETIC SURGERY FINANCIAL AGREEMENT 

I understand the procedure(s) I seek are cosmetic in nature, not medically necessary, and therefore it would be fraudulent and unethical for Thanapoom BoonipatMD to submit a fee to any insurance company for coverage. 

I have been shown and understand the financial costs of having Thanapoom BoonipatMD provide surgical care for me and accept these terms. 

I further understand that Thanapoom Boonipat MD will not accept insurance for this(these) procedure(s). 

My consent to have Thanapoom Boonipat provide care and not accept assignment from any insurance company, managed care provider, or other coverage source is irrevocable and final. 

I understand I will be fully responsible for the surgical/procedure fees for the surgery/procedures I seek. 

PATIENT CONSENT FOR USE OF CREDIT CARDS, DEBIT CARD, AND FINANCING DISCLOSURE OF PROTECTED HEALTH INFORMATION 

It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies, when requested, to facilitate your payment. 

Services that are performed and are paid with a credit card, debit card, or financing third party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Thanapoom Boonipat MD to use and disclose my protected health information to any credit card entity, bank, or financing company when they request such information to process an account and assist with payment. 

I will not challenge such credit, debit, or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise, which are further addressed in the Revision Policy. 

I agree that this non credit card challenge agreement is irrevocable. 

Patient or Person Authorized to Sign for Patient