HIPPA, Financial Policy & Bill of Rights

Elite Top Aesthetics

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), the Department of Health and Human Services, Office of Civil Rights, requires us to provide this revised Privacy Notice to our valued patients at Elite Top Aesthetics. This notice ensures that we meet all current standards for the privacy of individually identifiable health information (IIHI) that pertains to our patients. We strongly encourage you to read this notice.

As part of the Privacy Standard implemented on April 14, 2001, it is mandatory for you to provide our office with a new Consent Agreement that is signed and dated. Prior to using your information for treatment, payment, or other healthcare operations (TPO), every patient must receive our new Privacy Notice and complete a new Consent Agreement.

Our Privacy Notice outlines how we use and disclose your Protected Health Information (PHI). PHI is defined as any information, whether oral or recorded, that is created or received by a healthcare provider, health plan, public health authority, employer, life insurance company, school or university, or clearinghouse. This information relates to the past, present, or future physical or mental health or condition of an individual, the provision of healthcare to an individual, or the payment for the provision of healthcare to an individual.

For the purpose of treatment, payment, and other healthcare services, our office will use or disclose your PHI as permitted by your Consent Agreement or, in specific situations, by your signed and dated Authorization. We have established a policy to control access to your PHI, and even when access is permitted, we ensure that only the minimum necessary information is disclosed to fulfill the request.

An Authorization differs from a Consent Agreement in that it is specific about the information to be disclosed or used, the individual or entity receiving the information, the purpose of the disclosure, and the initiation date and duration of the authorization. This form is separate from the Consent Agreement and is typically used for a single request for information. If there is a non-healthcare related request for your personal health information, we will ask you to complete an Authorization Form.

As our patient, you have the right to revoke any Consent Agreement or Authorization at any time. Upon revocation, all use, disclosure, and administration of related healthcare services will be revised accordingly, except for matters that were already in process due to prior use of your PHI. To revoke either the Consent Agreement or the Authorization, you must provide our office with a written request that includes your signature, date, and specific instructions regarding the existing Authorization or Consent Agreement. Please note that any revocation will not affect information that has already been used or disclosed.

If a "personal representative" initiated an Authorization on your behalf, you have the right to revoke that authorization at any time.

As a patient, you have access to your healthcare information and may request to examine your information, obtain copies of your information, and request amendments to your information as permitted by law. The physician or principal will use professional judgment when considering requests for amendments and is not obligated by law to make any changes to the information. If the physician or professional agrees to amend the information, we are legally bound to abide by the changes.

Under certain circumstances, the Privacy Standard allows covered entities to continue disclosing health information without individual authorization for specific public responsibilities. These permitted disclosures include emergency situations, identification of a deceased person's body or determining the cause of death, public health needs, research with authorization waivers approved by a privacy board or Institutional Review Board, oversight of the healthcare system, judicial and administrative proceedings, limited law enforcement activities, and activities related to national defense and security. If state laws are more stringent than the HIPAA Privacy Standard, the state laws will take precedence when it comes to the disclosure of healthcare information related to Hepatitis C and AIDS.

While some disclosures of your PHI may be made to third parties, such as insurance companies for payment purposes or other healthcare providers for further treatment or additional services, we cannot guarantee that these parties will not use or disclose your PHI in a manner that violates the Privacy Standard, despite implementing contracts and monitoring. However, we strive to maintain a "chain of trust" to protect your information.

Although a signed and dated Privacy Notice is required by law, we do not make it a condition for receiving care that you sign this agreement. It is our duty to communicate your rights in this manner as mandated by the law.

To comply with the Privacy Standard, we have appointed a Privacy Officer, trained our Privacy Officer and staff on the law, and implemented policies to safeguard your PHI. We have also implemented privacy and security measures to protect your IIHI. Our office continuously monitors and improves these steps to ensure the protection of your information and compliance with the law.

Financial Policy January 2019

The consultation charge for Hormone Replacement is $175.00.

For a second surgical opinion within 3 months of a surgery performed elsewhere, the charge is $250; $500 if a letter is required.

Payment for injectable products such as Botox and Juvederm, as well as minor surgical procedures and skin care products, must be made on the day of service. We do not accept personal checks on the day of service.

If you choose to finance your payment through www.carecredit.com, please note that there will be a 6% transaction fee.

We consider approved methods of payment, other than cash, as full payment for the goods and services provided. Once these charges are paid, there will be no further recourse. By signing, you acknowledge that you trust us in good faith for all procedure and product charges.

Please understand that all services rendered to you will be directly charged to you, and you are personally responsible for payment. Refunds are not available. In the event of non-payment, you agree to bear the cost of collection, including court costs and reasonable legal fees, if necessary. Additionally, if you attempt to reverse credit, debit, or approved financing charges, you agree to reimburse Elite Top Aesthetics a chargeback processing fee of $250.00.

Charges for surgical procedure(s) represents a package charge, which includes the facility fee (42%), the provider fee (20%), anesthesia fee (16%), and operating room supplies (22 %) and includes all follow up visits with our experts.

There are no refunds for services or products. The facility does not in any way guarantee a particular result, nor are the fees quoted contingent upon any particular and/or desired outcome.

Expenses related to complications of cosmetic surgery are not usually covered by medical insurance and are the patient’s responsibility.

We are not affiliated with any insurance companies or health plans and we do not accept assignment from Medicare, Medicaid or any other insurance payer.

At no charge, we will provide you with ONE form you can submit to your insurance company for possible reimbursement after a surgical procedure and after each hormone pellet insertion. Because we do not participate with Medicare, you should not submit claims to Medicare, as Medicare will not honor submissions from non-participating physicians. There is a $35.00 charge per form, paid in advance, for the completion of any additional forms.

A non-refundable deposit of $1000.00 is required in order to schedule a surgical procedure. Surgery must be paid in full 7 days before the date of your procedure. The surgical fee does NOT include laboratory, pathology, or radiology charges, nor does it include emergency room visits, hospitalization, prescription medications, garments, bandages, office visits or procedures with other physicians. Your initial surgical fee does not cover revisions or future surgery

We understand that a situation may arise that could force you to postpone your surgery. Please understand that such changes affect not only your provider and office staff but other patients as well. If we are notified within 7 days of your surgery we will reschedule your procedure at no charge. If you need to cancel a surgical procedure with less than 7 days notice, your $1,000.00 deposit will not be returned nor can the deposit be used for a future procedure. If you choose to reschedule, you will be required to pay another non-refundable deposit of $1000.00 to secure your space on the surgical schedule.



Your confidential healthcare information may be released to other healthcare professionals within the organization for the purpose of providing you with quality healthcare.

Your confidential healthcare information may be released to your insurance provider for the purpose of the organization receiving payment for providing you with needed healthcare services.

Your confidential healthcare information may be released to public or law enforcement officials in the event of an investigation in which you are a victim of abuse, a crime or domestic violence.

Your confidential healthcare information may be released to other healthcare providers in the event you need emergency care.

Your confidential healthcare information may be released to a public health organization or federal organization in the event of a communicable disease or to report a defective device or untoward event to a biological product (food or medication).

Your confidential healthcare information may not be released for any other purpose than that which is identified in this notice.

Your confidential healthcare information may be released only after receiving written authorization from you.  This provision includes but is not limited to any psychotherapy notes, for marketing purposes and any disclosures that may constitute a sale of your protected healthcare information. Any other uses or disclosures not described in this notice can only be made with your express authorization. You may revoke your permission to release confidential healthcare information at any time.

You may restrict the disclosure of your protected health information for any services provided whereby your or somebody else pays “out of pocket”, in full, for the services.

You may be contacted by the organization to remind you of any appointments.

You have the right to opt out of notifications regarding healthcare treatment options, marketing and fundraising, or other health services that might be of interest to you.

You may be contacted by the organization for the purposes of raising funds to support the organization’s operations. It is your express right to opt out of any fund-raising communications.

You have the right to restrict the use of your confidential healthcare information.  However, the organization may choose to refuse your restriction if it is in conflict of providing you with quality healthcare or in the event of an emergency situation.

You have the right to receive confidential communication about your health status.

You have the right to review and photocopy any/all portions of your healthcare information.

You have the right to make changes to your healthcare information.

You have the right to know who has accessed your confidential healthcare information and for what purpose.

You have the right to possess a copy of this Privacy Notice upon request.  This copy can be in the form of an electronic transmission or on paper.

The organization is required by law to protect the privacy of its patients.  It will keep confidential any and all patient healthcare information and will provide patients with a list of duties or practices that protect confidential healthcare information.

The organization will promptly contact you should there be any breach of your protected health information.

The organization will abide by the terms of this notice.  The organization reserves the right to make changes to this notice and continue to maintain the confidentiality of all healthcare information.

You have the right to complain to the organization if you believe your rights to privacy have been violated.  If you feel your privacy rights have been violated, please mail your complaint to the organization:

ATTN: Elite Top Aesthetics Ÿ10377 S U.S. Hwy 1 #101 Ÿ Port St. Lucie FL, 34952

All complaints will be investigated.  No personal issue will be raised for filing a complaint with the organization.

For further information about this Privacy Notice, please contact:772-337-1642

This notice is effective as of 9/23/2013.  This date must not be earlier than the date on which the notice is printed or published.


Elite Top Aesthetics presents a Patient’s Bill of Rights with the expectation that observance of these rights will contribute to more effective patient care and greater satisfaction for the patient, his physician, and the group organization.  It is recognized that a personal relationship between the facility and the patient is essential for the provision of proper medical care.  The traditional physician-patient relationship takes on a new dimension when care is rendered within an organizational structure.  Legal precedent has established that the facility itself also has a responsibility to the patient.  It is in recognition of these factors that rights are affirmed.

The patient has the right:

  • To respectful treatment with concern for individual, cultural or educational difference.
  • To complete, up-to-date information about the condition, treatment and outlook for recovery.
  • To know who is responsible for the care provided.
  • To personal privacy and confidentiality in communication and medical records.
  • To an explanation of the various types of care to be received.
  • To refuse treatment, except in some cases where lifesaving treatment is mandated.
  • To know of any affiliations your hospital and physician(s) have with other institutions and physicians.
  • To change their provider if other qualified providers are available.

The patient has the responsibility:

  • To provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications including over the counter products and any dietary supplements and any allergies or sensitivities and other health related matters.
  • To report any unexpected change in condition to the responsible physician.
  • To say whether a contemplated course of treatment and the patient’s obligation in its administration are understood.
  • To follow the treatment plan recommended by the physician. The patient is expected to follow up on his/her doctor’s instructions, take medication when prescribed, and ask questions concerning his/her own health care that he/she feels is necessary.
  • To keep appointments or notify the appropriate person if it is not possible to do so.
  • To accept the consequences of choosing to ignore physician instructions or to refuse treatment.
  • To see that the financial obligations assumed in receiving health care are met as promptly as possible.
  • To inform the provider about any living will, medical power of attorney, or other directive that could affect his/ her care.
  • Be Respectful of all health care providers and staff, as well as other patients.

Patient Complaints and Compliments:

If you are dissatisfied or overly satisfied with any service you have received, please ask to speak to an Administrator so we may improve the quality of care.

No catalog of rights can guarantee for the patient the kind of treatment he has a right to expect.  Within this facility, all activities must be conducted with an overriding concern for the patient, and, above all, the recognition of his dignity as a human being.  Success in achieving this recognition assures success in the defense of the rights of the patient.