I hereby authorize Dr. Steven Warnock to release to my insurance carrier any medical information necessary to secure payment. I authorize benefits to be made payable directly to Dr. Steven Warnock. I understand that I am financially responsible to the physician for the charges not covered by my insurance policy. I certify that all information given on the patient information sheet is complete and correct to the best of my knowledge. In the event of default of payment of the chares, the responsible party agrees to pay collection fees, including reasonable attorney fees. This assignment will remain in effect until revoked by me in writing. A photocopy or digital facsimile of this assignment is considered as valid as the original.
I hereby give permission to Dr. Steven Warnock to render treatment as he sees fit upon myself, my son or daughter, or the person whom I have guardianship and to call any consultant, anesthesiologist, laboratory personnel, etc., as he deems advisable in the care of this case. I also agree to be responsible for the charges of any such consultants, as well as those of any hospitals, surgical centers, or medical facilities that may be incurred. I understand that the office takes all precautions to make sure my insurance carrier is contracted with these facilities, but I understand my insurance company does not guarantee payment. I hereby grant permission for the use of any record, illustration, photograph or other imaging record created in my case for the use in examination, testing, education, credentialing, and/or certifying purposes by The American Board of Plastic Surgery, Inc. or any other peer review or accrediting body. I am advised that although good results are expected, they cannot be and are not guaranteed, nor is there any guarantee against untoward results.
I have received or was offered a copy of the Notice of Privacy Practices provided by Dr. Warnock’s office in compliance with HIPPA regulations. I authorize Dr. Warnock to release my personal health information for use in “payment, treatment, and health care operations.” Copies are available at the front desk.
Non-emergency procedures require a 60% down payment prior to procedure. Our billing specialist is available to assist with payment arrangements. If for any reason an untimely financial situation arises, we encourage you to call our office and notify the billing specialist so arrangements can be made.
Cosmetic patients are required to pay a deposit equal to 10% of the price quote to secure any surgery date. This deposit is non-refundable. Payment in full for all surgeries is due one week prior to the surgery. No exceptions will be made. No personal checks are accepted. We accept credit cards ,money orders and cashiers checks. If you choose to finance through our finance company, all approvals must be received and signed before your surgery date.