Center for Plastic Surgery

Dell P. Smith, M.D.

Plastic and Reconstructive Surgery

Cosmetic Surgery

Thank you for choosing Center for Plastic Surgery. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy, which we require you read and sign prior to any treatment.

We will bill your insurance for you when applicable as a courtesy. We must have a copy of your card on file. As health care providers, our relationship is with you, not your insurance company. It is your responsibility to follow-up with your insurance and make sure they have received all of your claims. If you disagree on any payments or denials made by your insurance carrier, you must take appropriate action with them to file an appeal. Payment is your responsibility whether your insurance company pays or not. Please be aware that some, and perhaps all, services provided may be non-covered services and not considered reasonable and customary or necessary under the Medicare Program and/or other medical insurance. Our fees are based upon the usual and customary allowances for this area. All co-pays and deductibles are due prior to treatment.

COSMETIC PATIENTS: $500 DEPOSIT WILL BE COLLECTED AT THE TIME OF SCHEDULING SURGERY (NO EXCEPTIONS). THE BALANCE MUST BE PAID IN FULL TWO WEEKS BEFORE THE SURGERY. THE FEE OF $500 IS NONREFUNDABLE.

Dr. Dell Smith would enjoy the opportunity to extend professional courtesy discounts, however, we have been advised against this practice as it is violation of Health Care Financing Administration guidelines. Idaho Code Section 41-348 prohibits the regular practice of waiving, rebating, giving, paying (or the offer to do the same) a claimant’s deductible. This practice is also illegal under federal law (2002 OIG Special Advisory Bulleting “Offering Gifts and Other Inducements to Beneficiaries.”).

In accordance with the HIPPA Act of 1996, False Claims Act and the anti- kickback statute, we regret that we are unable to extend discounts except in extreme financial hardship cases.

FINANCE CHARGES will be charged to any unpaid accounts after 90 days from the date of service.

We will bill your claim to your insurance carrier; however, any correspondence that occurs will be between you and your insurance carrier.

INSURANCE PATIENTS: THE AMOUNT CHARGED IS AN ESTIMATE. I UNDERSTAND THAT OVERPAYMENT WILL BE REFUNDED AND THAT I AM RESPONSIBLE FOR ANY UNDERPAYMENT. PAYMENT IN FULL IS REQUIRED TWO WEEKS PRIOR TO SERVICE.

Your signature below signifies your understanding and willingness to comply with this policy.

Signature ____________________________________________ Date__________________

(If minor, parent/ legal guardian must sign)