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Secure Transaction
Billing Information
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Additional Information
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Please do NOT make payments for surgery online* PATIENT CONSENT FOR USE OF CREDIT/DEBIT CARDS & FINANCING DISCLOSURE OF PROTECTED HEALTH INFORMATION Services that are performed that are paid for with a credit card, debit card or financial third-party are not eligible for payment challenges and services are protected. By signing this form, I am irrevocably consenting to allow Aesthetic Surgery Associates to use and disclose my protected health information to any Credit Card Entity, Bank or Financing Company only when they request such information to process an account and assist with payments such as Health Savings or Flexible Spending Account. I will not challenge such credit, debit or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise. This non-credit card challenge agreement is irrevocable. Please note that you may refuse to sign this form. If you do refuse we cannot accept any form of payment by Credit or Debit cards including Flexible Spending or Health Savings Account.: