Edward M. Zimmerman, MD, PC, DBA Aesthetic Revolution Las Vegas will accept payment by cash, money order, or credit card. We do not accept personal or bank checks. You must be paid and full at the end of each appointment.
Appointments require a $150.00 deposit. The $150.00 deposit is applied towards any treatment or product sold in the office, or your next appointment deposit. In the case of a no show, reschedule with less than a 48 hour notice, late cancellation, or late arrival, the $150.00 deposit will not be applied/refunded.
A non-refundable 20% deposit is due at the time of booking a surgery and/or procedure exceeding $2,000. Surgery/procedure must be paid in full two (2) weeks prior to the surgery/procedure date.
Medical Records: Records released to the patient will be charged $0.60 per page copied. Payment in full must be received before your records will be released. Please allow ten (10) working days for your records to be copied.
Lab Charges: Lab charges are NOT included in your office visit. Charges for any lab work done in the office will be billed separately by a local lab. You will be getting a bill in the mail from the lab. We forward all billing information to the lab for insurance processing or private billing. If you have any questions, please contact the lab that sent you the bill.
Radiology: Radiology charges are NOT included in your office visit. The office will obtain authorization for any radiology procedures that Dr. Zimmerman or Dr. Lee feels are necessary to your health care. It is ultimately your responsibility to confirm if the facility and procedure is covered by your insurance.
If you have any questions or concerns, please feel free to ask a staff member for clarification.
Except for claims for emergency equitable or injunctive relief which cannot be timely addressed through arbitration, the Parties hereby agree to submit any claim or dispute arising out of the terms of this Agreement to private and confidential arbitration by a single neutral arbitrator in accordance with the rules of the American Arbitration Association. Such arbitration shall take place in Las Vegas, Nevada, and Nevada law will govern all issues. The determination of the arbitrator shall be conclusive and binding on the parties, and any determination by the arbitrator of an award may be filed with the clerk of a court of competent jurisdiction as a final adjudication of the claim involved, or application may be made to such court for judicial acceptance of the award and an order of enforcement, as the case may be. The arbitrator(s) shall designate the party to bear the expenses of the arbitrator(s) or the respective amounts of such expense to be borne by each party.
The parties understand that this Agreement contains an agreement to arbitrate. After adoption of this agreement the parties understand that neither will be able to bring a lawsuit concerning any dispute that may arise which is covered by the arbitration agreement, unless it involves a question of constitutional rights. Instead, each party agrees to submit any such dispute to an impartial arbitrator or arbitrators
If you have any questions or concerns regarding the Arbitration Agreement, please feel free to ask a staff member for clarification prior to signing the below Arbitration Acknowledgement.
, do hereby acknowledge that I have read this arbitration agreement and affirmatively agreed to and give this specific authorization to submit to arbitration any dispute arising between the parties to this Agreement, as provided above, and that I am bound to the same.
ACKNOWLEDGEMENT- RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of Edward M. Zimmerman, MD, PC, DBA Aesthetic Revolution Las Vegas’s “Notice of Privacy Practices.” This notice describes how Edward M. Zimmerman MD, PC, DBA Aesthetic Revolution Las Vegas may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.
ACKNOWLEDGEMENT- RECEIPT OF PATIENT RIGHTS & RESPONSIBILITIES
I acknowledge that I have received a copy of Edward M. Zimmerman, MD, PC, Aesthetic Revolution Las Vegas’s “Patient Rights & Responsibilities.” This notice describes my rights and responsibilities as a patient of this office.
ACKNOWLEDGEMENT AND CONSENT FOR NEEDLESTICK INCIDENT
I understand that sometimes in the course of treatment there can be an accident, whereby a needle used on me for treatment may somehow stick my caregiver. In the event this would occur, I give my full consent for Dr. Zimmerman and his staff to obtain the necessary blood samples for infectious disease testing recommended by OSHA standards. There will be no cost to me for this testing and I will provided copies of the results for my medical record.