Common use of Surgical Fees Clause in Contracts

Surgical Fees. Payment is due in full 3 weeks (21 days) prior to the scheduled surgery date. We accept Visa, Mastercard, Discover, American Express, CareCredit/Alphaeon, and Cashier Checks/Personal Checks. WE DO NOT ACCEPT CREDIT CARD CHECKS. All personal checks will be processed through TeleCheck as an electronic transfer. • If your surgery is cancelled or postponed 3 weeks (21 days) prior to surgery, your fees will be refunded. If your surgery is cancelled within the 3 weeks (21 days), you will be charged a $500.00 administrative fee and a fee for any services provided; such as laboratory work or skin care services. If your surgery is cancelled within seven (7) business days of your surgical date, an additional administrative fee of 25% of your total charges will be withheld from your refund. If your surgery is cancelled the day of the procedure, you will be charged 50% of the total charges. • Breast Reduction Procedures are considered cosmetic, unless deemed medically necessary per your insurance policy. We will file with your insurance as a courtesy; however, this does not guarantee your insurance company will reimburse. • All tissue that is removed during surgery will be sent to Pathology and the patient will be responsible for these charges. It is the patient’s responsibility to notify us regarding where their insurance prefers pathology to be sent to avoid out-of-network charges. • MEDICARE PATIENT’S: Medicare will not process any other provider’s claims (i.e. Coral Anesthesia/SaraPath) without receiving a claim from your surgeon. “Cosmetic and/or Non-Covered Medicare Services”, the patient is responsible for ALL fees associated with their surgery. Please note that Xx. Xxxxxx and Xx. Xxxxx do not participate with Medicare; therefore, ALL fees associated with surgery are the patient’s responsibility. • If postponing a surgery more than two (2) times, a 50% deposit will be required to hold a new surgical date and will be forfeited if date needs to be changed. In addition, such changes could result in dismissal from our practice at the surgeon’s discretion. • The services that are performed and paid for using a credit card or debit card are not eligible for credit card challenge. By signing this form, you are agreeing you will not challenge credit card payments once a service has been rendered. The practice encourages a complete post-op care and follow-up interaction to address any issues that might arise following services rendered. • Complimentary Botox® Cosmetic or Dysport® “Touch Up” appointments will only be honored between week two (2) and four (4) post initial injection. After four (4) weeks standard fees will apply. • The policies listed above will be applied in every situation. I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guarantee the payment of all amounts when and as due. A photocopy of this agreement shall be considered effective and valid as the original. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. MY SIGNATURE BELOW INDICATES I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS STATED IN THIS FINANCIAL AGREEMENT/ CANCELLATION POLICY. Patient Date Witness Date

Surgical Fees.  Payment is due in full 3 weeks fourteen (21 days14) days prior to the scheduled surgery date. We accept Visa, Mastercard, Discover, American Express, CareCredit/AlphaeonCare Credit, and Cashier Checks/Personal Checks. WE DO NOT ACCEPT CREDIT CARD CHECKS. If you would like to pay with a personal check then payment must be made at least 15 days prior to surgery. All personal checks will be processed through TeleCheck as an electronic transfer. •  If your surgery is cancelled or postponed 3 weeks fourteen (21 days14) days prior to surgery, surgery your fees will be refunded. If your surgery is cancelled within the 3 weeks fourteen (21 days), 14) days you will be charged a $500.00 400.00 administrative fee and a fee for any services provided; provided such as laboratory work or skin care services. If your surgery is cancelled within seven three (73) business days of your surgical date, date an additional administrative fee of 2520% of your total charges will be withheld from your refund. If your surgery is cancelled the day of the procedure, procedure you will be charged 50% of the total charges. •  If you pay your surgical fees with a major credit card the surgery cancellation fees stated above will apply. Additionally, you will be charged a service fee of 2.5% of the total xxxx for credit card services.  Breast Reduction Procedures are considered cosmetic, cosmetic unless deemed medically necessary per your insurance policy. We will file with your insurance as a courtesy; however, courtesy but this does not guarantee your insurance company will reimburse. • All In addition all tissue that is removed during surgery will be sent to Pathology and the patient will be responsible for these charges. It is the patient’s responsibility to notify us regarding where their insurance prefers pathology to be sent to avoid out-of-out of network charges. • MEDICARE PATIENT’S: Medicare will not process any other provider’s claims (i.e. Coral Anesthesia/SaraPath) without receiving a claim from your surgeon. “Cosmetic and/or Non-Covered Medicare Services”, the patient is responsible for ALL fees associated with their surgery. Please note that Xx. Xxxxxx and Xx. Xxxxx do not participate with Medicare; therefore, ALL fees associated with surgery are the patient’s responsibility. •  If postponing a surgery more than two (2) times, times a 50% deposit will be required to hold a new surgical date and will be forfeited if date needs to be changed. In addition, addition such changes could result in dismissal from our practice at the surgeon’s discretion. •  The services that are performed and paid for using a credit card or debit card are not eligible for credit card challenge. By signing this form, form you are agreeing you will not challenge credit card payments once a the service has been renderedprovided. The practice encourages a complete post-op care and follow-follow up interaction to address any issues that might arise following services renderedprovided. • Complimentary Botox® Cosmetic or Dysport® “Touch Up” appointments will only be honored between week two (2) and four (4) post initial injection. After four (4) weeks standard fees will apply. •  The policies listed above will be applied in every situation. I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guarantee the payment of all amounts when and as due. A photocopy of this agreement shall be considered effective and valid as the original. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. MY SIGNATURE BELOW INDICATES I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS STATED IN THIS FINANCIAL AGREEMENT/ CANCELLATION POLICY. Patient Date Witness Date.

Surgical Fees. Payment is due in full 3 weeks (21 days) prior to the scheduled surgery date. We accept Visa, Mastercard, Discover, American Express, CareCredit/Alphaeon, and Cashier Checks/Personal Checks. WE DO NOT ACCEPT CREDIT CARD CHECKS. All personal checks will be processed through TeleCheck as an electronic transfer. If you are paying with a Debit Card please verify with the bank your daily limit policy. • If your surgery is cancelled or postponed 3 weeks (21 days) prior to surgery, your fees will be refunded. If your surgery is cancelled within the 3 weeks (21 days), you will be charged a $500.00 administrative fee and a fee for any services provided; such as laboratory work or skin care services. If your surgery is cancelled within seven (7) business days of your surgical date, an additional administrative fee of 25% of your total charges will be withheld from your refund. If your surgery is cancelled the day of the procedure, you will be charged 50% of the total charges. • Breast Reduction Procedures are considered cosmetic, unless deemed medically necessary per your insurance policy. We will file with your insurance as a courtesy; however, this does not guarantee your insurance company will reimburse. • All tissue that is removed during surgery will be sent to Pathology and the patient will be responsible for these charges. It is the patient’s responsibility to notify us regarding where their insurance prefers pathology to be sent to avoid out-of-network charges. • MEDICARE PATIENT’S: Medicare will not process any other provider’s claims (i.e. Coral Anesthesia/SaraPath) without receiving a claim from your surgeon. “Cosmetic and/or Non-Covered Medicare Services”, the patient is responsible for ALL fees associated with their surgery. Please note that Xx. Xxxxxx and Xx. Xxxxx do not participate with Medicare; therefore, ALL fees associated with surgery are the patient’s responsibility. • If postponing a surgery more than two (2) times, a 50% deposit will be required to hold a new surgical date and will be forfeited if date needs to be changed. In addition, such changes could result in dismissal from our practice at the surgeon’s discretion. • The services that are performed and paid for using a credit card or debit card are not eligible for credit card challenge. By signing this form, you are agreeing you will not challenge credit card payments once a service has been rendered. The practice encourages a complete post-op care and follow-up interaction to address any issues that might arise following services rendered. • Complimentary Botox® Cosmetic or Dysport® “Touch Up” appointments will only be honored between week two (2) and four (4) post initial injection. After four (4) weeks standard fees will apply. • The policies listed above will be applied in every situation. I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guarantee the payment of all amounts when and as due. A photocopy of this agreement shall be considered effective and valid as the original. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. MY SIGNATURE BELOW INDICATES I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS STATED IN THIS FINANCIAL AGREEMENT/ AGREEMENT/CANCELLATION POLICY. Patient Date Witness Date

Surgical Fees. Payment is due in full 3 weeks (21 days) prior to the scheduled surgery date. We accept Visa, Mastercard, Discover, American Express, CareCredit/Alphaeon, and Cashier Checks/Personal Checks. WE DO NOT ACCEPT CREDIT CARD CHECKS. All personal checks will be processed through TeleCheck as an electronic transfer. If you are paying with a Debit Card please verify with the bank your daily limit policy. • If your surgery is cancelled or postponed 3 weeks (21 days) prior to surgery, your fees will be refunded. If your surgery is cancelled within the 3 weeks (21 days), you will be charged a $500.00 administrative fee and a fee for any services provided; such as laboratory work or skin care services. If your surgery is cancelled within seven (7) business days of your surgical date, an additional administrative fee of 25% of your total charges will be withheld from your refund. If your surgery is cancelled the day of the procedure, you will be charged 50% of the total charges. • Breast Reduction Procedures are considered cosmetic, unless deemed medically necessary per your insurance policy. We will file with your insurance as a courtesy; however, this does not guarantee your insurance company will reimburse. • All tissue that is removed during surgery will be sent to Pathology and the patient will be responsible for these charges. It is the patient’s responsibility to notify us regarding where their insurance prefers pathology to be sent to avoid out-of-network charges. • MEDICARE PATIENT’S: Medicare will not process any other provider’s claims (i.e. Coral Anesthesia/SaraPath) without receiving a claim from your surgeon. “Cosmetic and/or Non-Covered Medicare Services”, the patient is responsible for ALL fees associated with their surgery. Please note that Xx. Xxxxxx and Xx. Xxxxx do not participate with Medicare; therefore, ALL fees associated with surgery are the patient’s responsibility. • If postponing a surgery more than two (2) times, a 50% deposit will be required to hold a new surgical date and will be forfeited if date needs to be changed. In addition, such changes could result in dismissal from our practice at the surgeon’s discretion. • The services that are performed and paid for using a credit card or debit card are not eligible for credit card challenge. By signing this form, you are agreeing you will not challenge credit card payments once a service has been rendered. The practice encourages a complete post-op care and follow-up interaction to address any issues that might arise following services rendered. • Complimentary Botox® Cosmetic or Dysport® “Touch Up” appointments will only be honored between week two (2) and four (4) post initial injection. After four (4) weeks standard fees will apply. • The policies listed above will be applied in every situation. I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guarantee the payment of all amounts when and as due. A photocopy of this agreement shall be considered effective and valid as the original. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. MY SIGNATURE BELOW INDICATES I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS STATED IN THIS FINANCIAL AGREEMENT/ AGREEMENT/CANCELLATION POLICY. Patient Date Witness Date

Surgical Fees. Payment is due in full 3 4 weeks (21 28 days) prior to the scheduled surgery date. We accept Visa, Mastercard, Discover, American Express, CareCredit/Alphaeon, and Cashier Checks/Personal Checks. WE DO NOT ACCEPT CREDIT CARD CHECKS. All personal checks will be processed through TeleCheck as an electronic transfer. If you are paying with a Debit Card, please verify with the bank your daily limit policy. • If your surgery is cancelled or postponed 3 4 weeks (21 28 days) prior to surgery, your fees will be refunded. If your surgery is cancelled within the 3 4 weeks (21 28 days), you will be charged a $500.00 administrative fee and a fee for any services provided; such as laboratory work or skin care services. If your surgery is cancelled within seven fourteen (714) business days of your surgical date, an additional administrative fee of 25% of your total charges will be withheld from your refund. If your surgery is cancelled the day within 3 business days of the procedure, you will be charged 50% of the total charges. • Breast Reduction Procedures are considered cosmetic, unless deemed medically necessary per your insurance policy. We will file with your insurance as a courtesy; however, this does not guarantee your insurance company will reimburse. • All tissue that is removed during surgery will be sent to Pathology and the patient will be responsible for these charges. It is the patient’s responsibility to notify us regarding where their insurance prefers pathology to be sent to avoid out-of-network charges. • MEDICARE PATIENT’S: Medicare will not process any other provider’s provider claims (i.e. i.e., Coral Anesthesia/SaraPath) without receiving a claim from your surgeon. “Cosmetic and/or Non-Covered Medicare Services”, the patient is responsible for ALL fees associated with their surgery. Please note that Xx. Xxxxxx Xxxxxx, Xx. Xxxxx and Xx. Xxxxx do not participate with Medicare; : therefore, ALL fees associated with surgery are the patient’s responsibility. • If postponing a surgery more than two (2) times, a 50% deposit will be required to hold a new surgical date and will be forfeited if date needs to be changed. In addition, such changes could result in dismissal from our practice at the surgeon’s discretion. • The services that are performed and paid for using a credit card or debit card are not eligible for credit card challenge. By signing this form, you are agreeing you will not challenge credit card payments once a service has been rendered. The practice encourages a complete post-op care and follow-up interaction to address any issues that might arise following services rendered. • Complimentary Botox® Cosmetic or Dysport® “Touch Up” appointments will only be honored between week two (2) and four (4) post initial injection. After four (4) weeks standard fees will apply. • The policies listed above will be applied in every situation. I certify that I am the patient or that I am financially responsible for the services rendered and do hereby unconditionally guarantee the payment of all amounts when and as due. A photocopy of this agreement shall be considered effective and valid as the original. DO NOT SIGN THIS AGREEMENT UNLESS YOU UNDERSTAND ITS CONTENTS. MY SIGNATURE BELOW INDICATES I HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS STATED IN THIS FINANCIAL AGREEMENT/ AGREEMENT/CANCELLATION POLICY. Patient Date Witness Date