We want you to know what to expect so that you can make an informed decision. In order to accomplish this, by signing below you agree to the following:
I understand and acknowledge the procedures I seek will be considered cosmetic and it would be fraudulent and unethical for AIPS and/or Surgery Center of Texas to submit a charge to any insurance company for payment after services have been rendered.
I understand that AIPS and/or Surgery Center of Texas will not accept insurance for any procedures such as liposuction, facial feminization, breast augmentation, abdominal tightening, any MedSpa treatments, and extra skin removal.
I understand that AIPS and/or Surgery Center of Texas have my consent to not accept assignments from any insurance company, managed care provider, or another coverage source.
I understand that the self-pay amount is considered a “bundled” fee and will cover professional, facility, anesthesia, lab, and pathology services.
By my signature below, I acknowledge and agree to waive my insurance for any and all medical services at the American Institute of Plastic Surgery and Surgery Center of Texas. I understand I will be seen on a Self-Pay basis and will be 100% responsible for any associated charges pertaining to these services.
I confirm that I am the patient, or the patient’s duly authorized representative and agree that by accepting the self-pay agreement that I will not file my insurance after services have been rendered.