contact us today (949) 448-0487 Cosmetic Consultations are complimentary for existing & new patients. However, we do understand there are occasions where you may want to discuss pertinent dermatological issues with the providers the same day as your Cosmetic Consult or Cosmetic Treatments.
Dr. Lenore Sikorski and the NIOC staff would like to give you the proper time and attention when it comes to your dermatology concerns. Therefore, any medical evaluation and treatment (including medical prescriptions) completed at the same time as your Cosmetic Consult or Cosmetic Treatments will be billed to your insurance carrier. Any services rendered that are medically related will be subject to the details of your insurance plan, including your contracted specialist copay, deductible, and coinsurance.
By signing below, I understand I will be financially responsible for the charges billed today. The office will bill me or my insurance carrier for the dermatological services rendered today. I further understand the medical related services are NOT included in the Cosmetic Consult or Cosmetic Treatment I have received
Welcome and thank you for choosing our practice. Our goal is to provide excellent care and superior patient service. Our Polices are printed below. Your agreement to follow these policies will help us serve you.
-Our office accepts cash, personal checks, and debit cards, Visa, MasterCard, American Express, Discover and Care Credit. -If your insurance cannot be verified at the time of your visit, you may reschedule or be a Self-Pay patient. -Co-payments and account balances are due at the time of service.
-Partial payment may be required when scheduling cosmetic procedures -Refunds: Our office DOES NOT issue refunds for services rendered or products (incl. in-office prescriptions) purchased.
-To protect against fraud you MUST present your insurance card at each visit, and we REQUIRE a government-issued ID on file.
MEDICARE PATIENTS: If you are currently covered under Medicare, please present ALL insurance cards at the time of your visit. Medicare offers a Medicare Advantage plan in lieu of traditional Medicare. If you have chosen an Advantage plan and do not present the correct card, you will be responsible for any denied charges.
Labs:
-Lab tests ordered through our office are billed separately to your insurance from the laboratory. Patients are responsible for any lab charges.
-If your insurance requires that tests be sent to a specific lab, it is your responsibility to tell the Nurse, not the front desk, at the time the test is ordered.
Collections:
-Balances are due within 30 days of statement date.
-Past due balances: Outstanding balances are sent to a collections agency and your account with our practice may be closed. Patients Under 18 years old:
-The patient registration form must be signed and guaranteed by the legal guardian accompanying the minor at the first appointment. The “Responsible Party” is legally responsible for payment.
Fees: -Confirmation calls (made within 2 days of appointment) are considered a courtesy. We cannot be responsible for voicemails that are full and phone numbers that are disconnected. Patients are responsible for maintaining their appointment dates. To protect the practice, we must charge a “no show” or late cancelation fee for missed appointments. The fee is $50 for any missed, cancelled or rescheduled appointments without a 48 hour notice.
-Returned check fee: You will be responsible for the full amount of any check returned from the bank for non-payment, in addition to a $35 check return fee. A fee of $25 is assessed for printed medical records, medical letters for work, school, legal proceedings, health insurance, and paperwork for life insurance and disability applications.
By signing this form, I am stating that I have read the information above and understand my financial responsibility for my account.
The attached contract is an arbitration agreement. By signing this agreement we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both patients and physicians. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California courts.
By signing this agreement you are changing the place where your claim will be presented. You may still call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both patients and physicians. Further, both parties are spared some of the rigors of trial and the publicity that may accompany judicial proceedings.
Our goal, of course, is to provide medical care in such a way as to avoid any such dispute. We know that most problems begin with communication. Therefore, if you have any questions about your care, please ask us.
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether bron or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term "patient" herein shall mean the mother and the mother's expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician's partners, associates, association, corporation or partnership, and the employees, agents and estates of any if them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law: A demand for arbitration must communicate in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party's own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, nit supplant, any other applicable statutory or common law.
Either party shall have the absolute right ti arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in once proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days, or signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical services.
If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
A signed copy of this document is to be given to Patient. Original is to be files in Patient's medical records.
Day Cosmetic Consultation or Cosmetic Procedure
Cosmetic Consultations are complimentary for existing & new patients. However, we do understand there are occasions where you may want to discuss pertinent dermatological issues with the providers the same day as your Cosmetic Consult or Cosmetic Treatments.Dr. Lenore Sikorski and the NIOC staff would like to give you the proper time and attention when it comes to your dermatology concerns. Therefore, any medical evaluation and treatment (including medical prescriptions) completed at the same time as your Cosmetic Consult or Cosmetic Treatments will be billed to your insurance carrier. Any services rendered that are medically related will be subject to the details of your insurance plan, including your contracted specialist copay, deductible, and coinsurance
By signing below, I understand I will be financially responsible for the charges billed today. The office will bill me or my insurance carrier for the dermatological services rendered today. I further understand the medical related services are NOT included in the Cosmetic Consult or Cosmetic Treatment I have received
To Our Patients:
As of 7/17/2023, we have implemented a policy requiring a credit card to be held on file. Like hotels and car rental agencies, you are asked for a credit card number at the time you check in. The information will be held securely unless your insurance has paid their portion and notified us of the amount of your share. As you may be aware, the current healthcare market has resulted in multiple policy changes. The result may be increasing costs for patients. High deductible health plans are expanding more in healthcare and that means more financial responsibility for the patient. We need to ensure that patient balances are paid in a timely manner. Your credit card information is stored on a compliant & encrypted site which meets the payment card industry data security standards.
How does a credit card on file benefit me?
By keeping a credit card on file you will be able to: pay balances/co-pays conveniently, make payments automatically, avoid writing checks, and receive notifications and receipts sent via email.
Your credit card on file can be used for the following reasons:
copays, no show or late cancellation charges, product payments, cosmetic services rendered, deposits, payments not collected from you at the beginning of the visit and insurance discrepancies.
Please note all your rights with respect to the use of the card will remain in effect. This new policy will in no way prevent you from being able to dispute a charge or question your insurance company’s determination of payment. If you do not feel comfortable writing your card information in, you may provide your credit card to the NIOC staff who will directly input the information into our secure encrypted system. We understand that some patients are hesitant to provide their credit card information. If that is the case, we ask that you still sign the form below. This acknowledges that you have read the information above and are aware of our no show/cancellation policy.
Please sign below.