Please read all sections.
Thank you for choosing Revive Aesthetics & Regenerative Medicine as your healthcare provider. The medical services you seek imply an obligation on your part to read and acknowledge the policies stated herein.
Financial & Payment Policy
Our Patient Financial Policies will assist you in understanding your financial responsibility. By your acknowledgement of this form, you agree:
To be responsible for all payment obligations arising out of your treatment and guarantee payment at time services are rendered.
To follow all registration procedures, which include updating and verifying personal information, paying your patient responsibility amount at each visit. If you are not prepared to make your payment, your visit will be rescheduled
We accept payment by cash, debit cards, credit cards (Visa, MasterCard, Discover, American Express), Cherry Payment Plans, Care Credit and HSA/FSA Spending Account.
If you are paying by HSA/FSA Spending Account for products or services and your account provider denies the charges; you are solely responsible for returning the funds to your account holder. Revive Aesthetics and Regenerative Medicine will not process refund for services purchased.
When you pay by credit card your card may be held on file, you agree to keep the credit card information current, and you authorize to securely store your credit card information, and only charge it should you have an outstanding balance. The storage system used is fully compliant to the highest level of credit card storage security regulations.
Type of financing available:
Care Credit 0% Financing
Cherry Payment Plans - Apply Here: https://pay.withcherry.com/reviveregen?utm_source=practice&m=9503
Additional Charges. Patients may incur and are responsible for the payment of additional charges at the discretion of Revive Aesthetics & Regenerative Medicine, including but not limited to: charges for a missed appointment without 24 hours advance notice; any costs associated with collection of patient balances, all as allowed by law.
Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s treatment at time of service as well as any unpaid account balance. A minor who is not accompanied by a parent/guardian will not be treated unless charges for the treatment have been pre-paid and an authorization for treatment is on file.
Authorization to Contact. You authorize Revive Aesthetics & Regenerative Medicine personnel and any agent/servicer of your patient account to communicate by mail, voice messages, text messages, and/or e-mail according to the information provided in your Patient Information form for purposes related to your account, including collections. You expressly consent to any such contact being made by the most efficient technology available, including automatic dialing/emailing/text messaging even if you are charged for the contact.
Financially Responsible Party. If this or a separate Patient Financial Policies form is signed by another person, on your account, then that co-signature remains in effect until cancelled in writing. Cancellation in writing shall become effective the date after receipt, and shall apply only to those services and charges thereafter incurred. By signing as a financially responsible party, you hereby guarantee the full and prompt payment to Revive Aesthetics & Regenerative Medicine of all indebtedness of patient to the practice, whether now existing or hereafter created (the “Indebtedness”); and you further agree to pay all expenses, legal or otherwise, incurred by Revive Aesthetics & Regenerative Medicine in collecting the Indebtedness, in enforcing this guaranty, or in protecting its rights under this guaranty or under any other document evidencing or securing any of the Indebtedness. This guaranty shall be a continuing, absolute and unconditional guaranty, and will remain in force and effect until any and all said Indebtedness will be fully paid.
Refund Policy
Services. NO REFUNDS WILL BE GIVEN ON SERVICES PURCHASED, NO EXCEPTIONS. You may use funds paid for alternate service if necessary and must be approved by management. Any funds used to purchase services can not be used for skincare products.
Products. Unopened products may be exchanged or returned for full refund within 30 days of purchase date. There are no refunds on opened products for health safety reasons - we may offer a full refund as a store credit if adverse reactions occur with your skin.
Discounted Packages. With many of our services Revive Aesthetics & Regenerative Medicine offers the ability to pay per treatment (pay-as-you-go) or receive a discount for buying a package (paying up-front). We are happy to offer this discount on our packages, but must charge the pay-as-you-go fee if the package is disrupted prior to completion.
If discontinuation of your purchased package occurs before you have reached the end of treatment, you will be charged the list price for services already rendered.
Appointment & Cancellation Policy
All appointments require a credit card to be saved on file
All appointments require a $50 deposit which will be credited towards your treatment if it's same day. If no treatment is performed same day, the $50 fee will be charged towards your consultation visit. This fee is non-refundable.
As a courtesy, we provide appointment reminders for patients via text and email. If you need to reschedule or cancel, please contact us by phone or email 24 hours in advance of your scheduled time. It is important that you cancel and/or reschedule with our office during Business Hours (Monday through Friday).
All rescheduling/cancellations with less than 24 hours' notice are subject to a $50 fee and/or 20% of prepaid services and will be charged to your card on file. By scheduling an appointment, you are agreeing to our Appointment & Cancellation Policy.
This includes any appointments for free services.
Late Arrivals
Patients arriving more than 15 minutes late may result in a shortened appointment or will be rescheduled if there is not enough time to complete the procedure. We have the right to reschedule your appointment to give you quality treatment and to respect other patients’ scheduled appointments
We appreciate your cooperation and we look forward to your appointment.
Photography Consent and Release Form
I consent for photographs and/or video images to be taken of me by Revive Aesthetics & Regenerative Medicine or a representative. I understand the images will be a part of my medical record and may be used for purposes of medical teaching or training or for marketing purposes (website, print, digital or social media). By consenting to photographs and/or video images I understand I will not be compensated from any party. Although photographs and/or video images will be used without identifying information such as name, I understand it is possible someone may recognize me. I further acknowledge that my participation is voluntary and agree that use of any photographs and/or video images confers no rights of ownership or royalties whatsoever.
Please note that all "model" treatments for training will require photo/video at time of service and may be used for training, social media and on our website.
Uses and Disclosures of Protected Health/Personal Information
Your protected health/personal information may be used and disclosed by our medical director, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you to support business operations of this office, if requested by you to a finance company to pay for your care, and any other use required by law.
Treatment: We will use and disclose your protected health/personal information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health/personal information, as necessary, if, as a result of our services, you require treatment by a physician. Your protected health/personal information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health/personal information will be used, if requested, to obtain payment for your services. For example, if you desire to finance the costs of your treatments, this may involve disclosing relevant protected private information in order to obtain approval.
Healthcare Operations: We may use or disclose, as needed, your protected health/personal information in order to support the business activities of this office. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health/personal information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health/personal information in the following situations without your authorization. These situations include: as required by law; public health issues as required by law, communicable diseases; health oversight; abuse or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; coroners, funeral directors and organ donation; research; criminal activity and national security; workers� compensation; inmates; required uses and disclosures. Under the law, we must make disclosure to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that this office has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights
Following is a statement of your rights with respect to your protected health/personal information.
You have the right to inspect and copy your protected health/personal information. Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health/personal information that is subject to law that prohibits access to protected health/personal information.
You have the right to require a restriction of your protected health/personal information. This means you may ask us not to use or disclose any part of your protected health/personal information for the purposes of treatment or healthcare operations. You may also request that any part of your protected health/personal information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
We are not required to agree to a restriction that you may request. If our medical director believes it is in your best interest to permit use and disclosure of your protected health/personal information, your protected health/personal information will not be restricted. You then have the right to use another service provider.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically.
You may have the right to amend your protected health/personal information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to our statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health/personal information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2009.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health/personal information. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our Main Phone Number.
