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Pacific Center for Plastic Surgery requires all medical services to be paid in advance. A $500.00 administration fee is required at the time of scheduling for all surgical procedures. This fee is applied towards your surgery. The remaining surgery balance must be paid in full at the pre-op or the pre-op appointment will be rescheduled. If the pre-op appointment is rescheduled, the surgery date may have to be rescheduled also. Surgery cancellations require notice to our office in writing. If the cancellation request is after the pre-op appointment and prescriptions have been issued, no refunds will be made until the prescriptions are returned to the office. We will not reimburse prescription fees if prescriptions have been filled. If surgery is cancelled, the administration fee will be retained by the Pacific Center for Plastic Surgery. The work of our staff on behalf of our patient intensifies when the patient elects for surgery. In an effort to provide the best possible service to all patients, the administrative fee is necessary to offset some of the expenses of a cancelled surgery. Cancelled surgeries financed through one of our office finance plans will be held to the cancellation policies of the financing company. If surgery must be cancelled due to illness or any other circumstance, the standard fees as listed above will be assessed if surgery is not rescheduled. The patient shall be liable for 50% of the Surgeon\u2019s Fee and 100% of Supply Charges if a scheduled surgery is cancelled within less than 5 business days of the surgery. Required lab work, prescriptions, garments, and pathology, if needed, are the financial responsibility of the patient. This document outlines the cancellation policies of the Pacific Center for Plastic Surgery; patients are advised to review the cancellation policies for the selected surgery center, regarding operating room and anesthesia fees, as they may differ from our office policy. As explained in the initial office visit with \u2587\u2587. \u2587\u2587\u2587\u2587\u2587\u2587\u2587\u2587 or \u2587\u2587. \u2587\u2587\u2587\u2587\u2587\u2587\u2587, there are risks associated with all surgeries. While the risks are low, they must be addressed before surgery so misunderstandings are avoided post-operatively. Should a revision become necessary, there will be an extra financial obligation on your part. If a revision is needed and the patient has remained compliant, i.e.: followed recommended follow-up schedule, followed the doctors recommendations, and has not undergone significant physical body changes, the patient will only be responsible for outside fees such as supplies, operating room, and anesthesia. It is our goal to exceed the expectations of every patient. Upon completion of medical services no refunds will be made. All fees are based on a surgical time assessed to each individual case. Should your surgery go beyond the scheduled amount of time, the patient will not be billed for any additional surgeon\u2019s fee; however, the patient will be responsible for the additional surgery center and anesthesia fees.", "hash": "2187306aa9d7f1b687a6e2aa4650adca", "id": 1}, {"samples": [{"hash": "hkUaIklagbB", "uri": "/contracts/hkUaIklagbB#patient-name", "label": "Patient Treatment & Financial Agreement", "score": 33.4131467583, "published": true}, {"hash": "enCgCxQXFeG", "uri": "/contracts/enCgCxQXFeG#patient-name", "label": "Patient Treatment & Financial Agreement", "score": 26.2142368241, "published": true}], "snippet_links": [{"key": "patient-signature", "type": "definition", "offset": [0, 17]}, {"key": "guardian-signature", "type": "definition", "offset": [39, 57]}], "size": 2, "snippet": "Patient Signature: Date: Relationship: Guardian Signature (if patient is a minor):", "hash": "965cf449bb1b22a15bc38433a9313941", "id": 2}, {"samples": [{"hash": "7C9F0lxFH71", "uri": "/contracts/7C9F0lxFH71#patient-name", "label": "Appointment Confirmation", "score": 19.4387405886, "published": true}], "snippet_links": [{"key": "responsible-party", "type": "definition", "offset": [6, 23]}], "size": 1, "snippet": "Date: Responsible Party: Relationship to patient: Signature: Witness Initials:", "hash": "8f7d3186bece7523e80fc01a8212c33d", "id": 3}, {"samples": [{"hash": "kKAVVbGHPSz", "uri": "/contracts/kKAVVbGHPSz#patient-name", "label": "Social Worker Patient Services Agreement", "score": 24.4209445585, "published": true}], "snippet_links": [{"key": "social-security", "type": "clause", "offset": [14, 29]}, {"key": "should-know", "type": "definition", "offset": [36, 47]}, {"key": "treatment-work", "type": "definition", "offset": [93, 107]}, {"key": "all-records", "type": "clause", "offset": [360, 371]}, {"key": "strictest-confidence", "type": "clause", "offset": [392, 412]}, {"key": "written-consent", "type": "definition", "offset": [457, 472]}, {"key": "federal-law", "type": "definition", "offset": [501, 512]}, {"key": "state-law", "type": "clause", "offset": [534, 543]}, {"key": "abuse-or-neglect-of-minors", "type": "definition", "offset": [590, 616]}, {"key": "vulnerable-adults", "type": "definition", "offset": [647, 664]}, {"key": "legal-duty", "type": "clause", "offset": [694, 704]}, {"key": "psychological-services", "type": "definition", "offset": [852, 874]}], "size": 1, "snippet": "DOB: Address: Social Security#: You Should Know the Following \u2022 Psychotherapy evaluation and treatment work best when you and your doctor work cooperatively. \u2022 During the course of your evaluation/treatment, you may discuss things that will be upsetting but necessary to help you resolve your psychological difficulties. \u2022 What you and your doctor discuss and all records will be held in the strictest confidence. Information can only be released with your written consent, except where stated and/or federal law directs otherwise. \u2022 State law requires that your doctor report all cases of abuse or neglect of minors and, in some states, abuse of vulnerable adults as well. \u2022 Your doctor has a legal duty to take action and break confidentiality if you are a danger to yourself or others. \u2022 Please ask your doctor any questions you may have about your psychological services.", "hash": "a29eb34ca240a54062e1ea9930c3d0ed", "id": 4}, {"samples": [{"hash": "1sflEWKrVV1", "uri": "/contracts/1sflEWKrVV1#patient-name", "label": "Patient Provider E Mail Agreement", "score": 24.0622589202, "published": true}], "snippet_links": [{"key": "patient-signature", "type": "definition", "offset": [0, 17]}, {"key": "mail-address", "type": "definition", "offset": [21, 33]}, {"key": "state-of-residence", "type": "definition", "offset": [41, 59]}], "size": 1, "snippet": "Patient Signature: E-mail Address: Date: State of residence: _", "hash": "c700d51557c32a4d1fe95889bc9b9af9", "id": 5}, {"samples": [{"hash": "cNiNemm7eFz", "uri": "/contracts/cNiNemm7eFz#patient-name", "label": "Arbitration Agreement", "score": 19.2503147139, "published": true}], "snippet_links": [{"key": "parent-or-guardian", "type": "definition", "offset": [17, 35]}, {"key": "witness-name", "type": "definition", "offset": [54, 66]}], "size": 1, "snippet": "Signature: Date: Parent or Guardian: Signature: Date: Witness Name: Signature: Date:", "hash": "33ebdf9e62db716d1f00ad64545b25e2", "id": 6}, {"samples": [{"hash": "kQsQp3wyc7S", "uri": "/contracts/kQsQp3wyc7S#patient-name", "label": "Financial Agreement", "score": 29.726304572, "published": true}], "snippet_links": [{"key": "insurance-company", "type": "definition", "offset": [5, 22]}, {"key": "dates-of-service", "type": "clause", "offset": [30, 46]}, {"key": "out-of-pocket", "type": "definition", "offset": [93, 106]}], "size": 1, "snippet": "DOB: Insurance Company: ID #: Dates of service: In-Network / Out-of-Network Deductible: Met: Out of Pocket Max: Met: Deductible Applies Y / N Co-Pay: $ Co-Insurance: % Chiro Visits: $ Amount:", "hash": "07033dae3be5b46d73c0c6808caaafa8", "id": 7}, {"samples": [{"hash": "1QqeZ2IEHdF", "uri": "/contracts/1QqeZ2IEHdF#patient-name", "label": "Urgent Access Membership Agreement", "score": 29.3364394528, "published": true}], "snippet_links": [], "size": 1, "snippet": "Signature:", "hash": "4d89fe5ed734bd5964f2dd9a8b06f964", "id": 8}, {"samples": [{"hash": "6Pir57NwPYy", "uri": "/contracts/6Pir57NwPYy#patient-name", "label": "NHS Standard Contract for Specialised Rehabilitation", "score": 25.2843583056, "published": true}], "snippet_links": [{"key": "length-of-stay", "type": "definition", "offset": [28, 42]}], "size": 1, "snippet": "Diagnosis: Admission Dates: Length of Stay: Discharge destination: Home", "hash": "a28134b8289d50e3f7ec1cd42452b584", "id": 9}, {"samples": [{"hash": "k5uVQPhWsia", "uri": "/contracts/k5uVQPhWsia#patient-name", "label": "Informed Consent Agreement", "score": 25.3994044631, "published": true}], "snippet_links": [], "size": 1, "snippet": "[PatientFirstname] [PatientLastname] Consultant: \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026.", "hash": "50687452e9be4a761f4fb0cdd5edb8f1", "id": 10}], "next_curs": "ClkSU2oVc35sYXdpbnNpZGVyY29udHJhY3RzcjULEhpEZWZpbml0aW9uU25pcHBldEdyb3VwX3Y1NiIVcGF0aWVudC1uYW1lIzAwMDAwMDBhDKIBAmVuGAAgAA==", "definition": {"title": "Patient Name", "size": 22, "snippet": "DOB: Please initial each clause and sign below to indicate you have read and understand the fee agreement. Pacific Center for Plastic Surgery requires all medical services to be paid in advance. A $500.00 administration fee is required at the time of scheduling for all surgical procedures. This fee is applied towards your surgery. The remaining surgery balance must be paid in full at the pre-op or the pre-op appointment will be rescheduled. If the pre-op appointment is rescheduled, the surgery date may have to be rescheduled also. Surgery cancellations require notice to our office in writing. If the cancellation request is after the pre-op appointment and prescriptions have been issued, no refunds will be made until the prescriptions are returned to the office. We will not reimburse prescription fees if prescriptions have been filled. If surgery is cancelled, the administration fee will be retained by the Pacific Center for Plastic Surgery. The work of our staff on behalf of our patient intensifies when the patient elects for surgery. In an effort to provide the best possible service to all patients, the administrative fee is necessary to offset some of the expenses of a cancelled surgery. Cancelled surgeries financed through one of our office finance plans will be held to the cancellation policies of the financing company. If surgery must be cancelled due to illness or any other circumstance, the standard fees as listed above will be assessed if surgery is not rescheduled. The patient shall be liable for 50% of the Surgeon\u2019s Fee and 100% of Supply Charges if a scheduled surgery is cancelled within less than 5 business days of the surgery. Required lab work, prescriptions, garments, and pathology, if needed, are the financial responsibility of the patient. This document outlines the cancellation policies of the Pacific Center for Plastic Surgery; patients are advised to review the cancellation policies for the selected surgery center, regarding operating room and anesthesia fees, as they may differ from our office policy. As explained in the initial office visit with \u2587\u2587. \u2587\u2587\u2587\u2587\u2587\u2587\u2587\u2587 or \u2587\u2587. \u2587\u2587\u2587\u2587\u2587\u2587\u2587, there are risks associated with all surgeries. While the risks are low, they must be addressed before surgery so misunderstandings are avoided post-operatively. Should a revision become necessary, there will be an extra financial obligation on your part. If a revision is needed and the patient has remained compliant, i.e.: followed recommended follow-up schedule, followed the doctors recommendations, and has not undergone significant physical body changes, the patient will only be responsible for outside fees such as supplies, operating room, and anesthesia. It is our goal to exceed the expectations of every patient. Upon completion of medical services no refunds will be made. All fees are based on a surgical time assessed to each individual case. Should your surgery go beyond the scheduled amount of time, the patient will not be billed for any additional surgeon\u2019s fee; however, the patient will be responsible for the additional surgery center and anesthesia fees.", "id": "patient-name", "examples": ["<strong>Patient Name</strong> / / Patient/Health Care Agent/Guardian/Relative Signature Date It is the policy of Women\u2019s Health Associates of Southern Nevada to inform patients of the availability of an Advance Directive form.", "<strong>Patient Name</strong> Birth Date \u2022 Any other providers involved in my medical care to release my records to Pelorus Elder &amp; Behavioral Health.", "<strong>Patient Name</strong> (printed): Date of Birth: / / Signature of Patient (or representative): Date: / / Relationship (If other than patient): Consent Denied: Date: / / We provide an online Patient Portal to make managing your health care simple and convenient.", "<strong>Patient Name</strong> / / Patient/Health Care Agent/Guardian/Relative Signature Date THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.", "<strong>Patient Name</strong>: _ _ Patient Signature: _ __ _Date: _ Signature: _Date: \u2587\u2587\u2587\u2587\u2587\u2587\u2587 \u2587.", "Signature of Patient/Legal Guardian Date Signature of Provider Date NL-MH_302 NL-MH_InformedConsent0519 <strong>Patient Name</strong>: DOB: \u2022 The right to be informed of your rights as a patient/client.", "The following are possible reasons for an involuntary discharge: \u2022 referral to another treatment resource is deemed necessary by your provider \u2022 excessive missed appointments <strong>Patient Name</strong>: DOB: I understand that I am seeking services regarding a health problem or suspected health problem at NorthLakes Community Clinic (NorthLakes) to be provided by authorized employees of the Clinic, etc.", "<strong>Patient Name</strong> (Print): Patient Signature: Date: / / I, have been given an office financial policy form and have read and agree to provide my credit card information to process any patient responsibility after claims finalize with my insurance carrier.", "<strong>Patient Name</strong>: __________________________ DOB ______________ or MRN ____________________ I/we have acknowledged that I/we have carefully reviewed and agreed to abide by the Guest Rules and Guidelines.", "<strong>Patient Name</strong>: Date of Birth: Financial Policy Rev 08/2019 I have read and understand this financial policy of Saint Sophie\u2019s and I agree to be bound by its terms."], "related": [["product-name", "Product name", "Product name"], ["contact-name", "Contact Name", "Contact Name"], ["print-name", "Print Name", "Print Name"], ["project-name", "Project Name", "Project Name"], ["pharmacist-services", "Pharmacist services", "Pharmacist services"]], "related_snippets": [], "updated": "2025-07-06T21:58:36+00:00"}, "json": true, "cursor": ""}}