Financial Terms and Conditions
Many health insurance companies do not cover cosmetic surgery and/or treatment procedure(s), whether initial or revisionary. Please carefully review with your health insurance plan in advance whether the proposed or desired surgical and/or treatment procedures are covered by your health insurance.
Please note that payment is due at the time services are rendered. The fees charged for your procedure(s) do not include any potential future costs, in the event you choose to have or require additional procedures to revise, enhance or complete your care and treatment with us. Thank you for your cooperation and understanding.
Deductible, Co-Insurance, and Co-Payment
If you have health insurance which covers the surgical and/or treatment procedure(s), you are responsible for necessary deductible, co-insurance, and co-payments. Your co-payment is due at the time of service, and co-insurances are settled once the claim is adjudicated. If your deductible has not yet been met, payment may also be required at the time of service.
If services provided are not covered by your health insurance carrier, you will be responsible for necessary payments for those charges not covered. Your e-signature below constitutes agreement to pay for such services.
As an out-of-network provider and laboratory, and with the potential of utilizing an out-of-network outpatient surgery facility, none of the parties involved have a contract with your health insurance carrier. As a result, you may be financially responsible for a higher share of the fees than a provider, laboratory, or facility within your network. Your signature below constitutes agreement to pay for the applicable portion of the out-of-network fees.
The insurance process will begin once your procedure has been completed. There are four entity claims that will be submitted to your insurance on your behalf – surgeon, facility, anesthesia, and laboratory (pathology). The insurance may take between sixty and ninety days to finalize all four claims, and possibly longer if an appeal is necessary. Please refer to the billing page within the FAQ section of our website for detailed information, along with all the appropriate contacts for each entity that submits to your insurance. Please contact the appropriate parties immediately upon receiving your invoice so that we can begin assisting you with the insurance process.
Member Appeal Representation Authorization
In the event your claim is denied and/or processed by your insurer but below your applicable level of benefits, you request and grant authorization to Bespoke Surgical, P.C, and its agents, contractors and employees to represent you and act on your behalf regarding your medical health claim determination. This authorization will expire upon resolution of the appeal.
“No-shows” and Late Cancellations
In an effort to reduce the number of such occurrences, which inconveniences both our staff and our other clients, we have implemented a Medical Appointment Cancellation Policy and it is effective immediately. Our office makes reminder calls and sends out reminder emails for all appointments — office visits and surgeries — unless you specifically opt-out. It is ultimately the client’s responsibility to not only remember their scheduled appointments, but also to confirm their scheduled appointments. Our policy is as follows: (1) We kindly ask that you please confirm your appointment by either replying to our email or calling our office at 212-206-1501 24 business hours prior to your appointment. Because Dr. Goldstein is extremely busy, we do require a confirmation. If you do not confirm within 24 hours, we will assume you will not be keeping your appointment & will offer it to another patient. If you show to an appointment without confirming & the appointment has already been given away, we will reschedule you to the next available date. (2) We request you give our office a 24 business hour notice in the event you need to cancel or reschedule your appointment — either office visit or surgery (for example, if your appointment is on a Monday, you must cancel by that time on Friday). Our phone number is (212) 206-1501 and our email is email@example.com. (3) If you do not show up for an office visit and do not contact us with at least a 24 business hour prior notice, we will consider this a missed office visit, and a $75.00 no-show fee will be assessed to you for first time infractions. This applies to late cancellations (less than 24 business hours), late rescheduling (less than 24 business hours), and “no-shows”. For all future infractions, a $150.00 fee with be assessed. (4) If you do not show for a surgery and do not contact us with at least a 24 business hour prior notice, we will consider this a missed surgery and a $300 no-show fee will be assessed to you. This applies to late cancellations (less than 24 business hours), late rescheduling (less than 24 business hours), and “no-shows”. (5) If you are late for an appointment, you will be charged a $15 late fee, and you will be given the possibility of being rescheduled to the next available appointment, according to how late you are. Unfortunately, we cannot make any guarantees that you will be seen same-day. These fees will be billed to you directly and are not covered by your insurance. When you come in for your initial appointment, we will ask for a credit card to be placed on file. Fees that you have incurred will be charged at the time of infraction and if payment cannot be processed, your balance will be subject to collections.
I understand that with cosmetic surgical and/or treatment procedure(s), I am responsible for the surgical fees quoted to me, as well as additional fees for facility, anesthesia, and pathology; these might also include X-ray, lab and other expenses as appropriate for my care and treatment. I understand the above Financial Terms and Conditions, and I unconditionally and irrevocably accept the financial responsibilities as outlined above. If a secondary procedure is necessary, I understand further costs will be incurred, and I am responsible for such costs as outlined above.
By clicking “agree”, I acknowledge that I have read and agree to the Financial Terms and Conditions and intend to be bound by them. I understand that my electronic signature has the same legal effect and can be enforced in the same way as a written signature.