TERMS OF USE AND FINANCIAL POLICY & GOOD FAITH ESTIMATE 

Financial Policy & Self-Pay Agreement

 

Applies whether you are uninsured or have insurance but elect not to submit a claim.

A. Cash-Pay Status & Payment Responsibility

ONE HOUSE OF DERM, LLC is a cash-pay practice. Payment is due at the time services or products are provided unless the Practice agrees in writing to another arrangement.

ONE HOUSE OF DERM, LLC does not submit claims to commercial insurance, Medicare, Medicaid, Medicare Advantage, Medigap, or other health plans. You are responsible for the full charge, regardless of whether you have coverage or whether your plan might otherwise cover an item or service.

If you are a Medicare beneficiary, Dr. Zabielinski has opted out of the Medicare program. Before receiving any non-emergency service, you will be asked to review and sign a separate Medicare Private Contract, which explains that Medicare will not pay for services provided under this arrangement and describes your rights as a Medicare beneficiary in more detail.

At your request, the Practice may provide a receipt or information you may independently submit to a plan. The Practice does not guarantee reimbursement, does not represent that any service is covered, and is not responsible for denials, deductible amounts, network status, coding determinations, or benefit limitations.

You authorize the Practice to collect amounts you approve by credit/debit card, cash, check, or another accepted method. Returned payments, chargebacks, or disputed transactions do not eliminate a valid balance.

B. Appointment Deposits, Cancellations, Late Arrivals & No-Shows

Appointment Type

Deposit

How It's Handled

Medical dermatology visit

$50

Applied to the visit when kept

Botox/Dysport appointment

$50

Applied to treatment when kept

SkinPen microneedling

$50

Applied to treatment when kept

Any appointment involving filler

$100

Applied to treatment when kept

Autologous Platelet-Rich Plasma / Fibrin (PRP/PRF)

$100

Applied to treatment when kept

Deposits are non-refundable. When the appointment is kept, the deposit is credited toward the visit or procedure performed that day.

With at least 24 hours' notice, a deposit may remain as a credit on your account for a rescheduled appointment, subject to Practice approval. It is not redeemable for cash.

Cancellation with less than 24 hours' notice or failure to appear results in forfeiture of the applicable deposit. If no deposit was collected, the Practice may charge the corresponding $50 or $100 fee.

Arriving late may shorten your appointment, require rescheduling, or be treated as a late cancellation when the service cannot be safely completed without disrupting other patients.

Repeated late cancellations, no-shows, chargebacks, or unpaid balances may require full prepayment before future scheduling, or may result in discharge from the Practice, consistent with applicable professional obligations.

C. Products, Procedures, Packages & Gift Cards

Professional fees are earned when services are rendered. Cosmetic outcomes are individualized and are not guaranteed. Dissatisfaction with an expected or subjective result, duration of effect, bruising, swelling, asymmetry during healing, or the need for additional treatment does not by itself create a right to a refund.

Skincare and retail products are final sale once dispensed or opened. A product may be replaced or refunded when it was expired at the time of sale, defective, damaged before delivery, or the wrong item was dispensed, subject to verification and applicable law.

Treatment packages are non-transferable, have no cash value, and expire 12 months after purchase. Unused sessions after expiration are forfeited unless an extension is required by law or approved in writing by the Practice for documented exceptional circumstances.

Gift cards are non-transferable and are not redeemable for cash except where required by law. Gift cards are separate from treatment packages. Any expiration, inactivity fee, replacement, or redemption rule will be administered in accordance with applicable federal and Alabama law.

Promotions, discounts, package pricing, loyalty credits, and gift cards generally may not be combined unless the Practice states otherwise in writing.

D. Outside Providers & Separate Charges

Fees charged by ONE HOUSE OF DERM, LLC cover only items and services provided by ONE HOUSE OF DERM, LLC unless the estimate specifically says otherwise.

Independent laboratories, pathology groups, pharmacies, imaging centers, hospitals, consultants, and other outside providers may bill you separately. Their fees are not controlled by ONE HOUSE OF DERM, LLC and may not be included in the Practice's estimate.

When federal law requires an outside provider or facility to issue its own Good Faith Estimate, that provider or facility is responsible for its estimate. ONE HOUSE OF DERM, LLC will make reasonable efforts to identify expected outside services but cannot guarantee another entity's price, insurance participation, or billing practices.

If a specimen is sent to an outside pathology laboratory, the pathology interpretation and related testing may generate a separate charge.

E. Personal Belongings

Keep valuables secure and bring only necessary personal items. To the fullest extent permitted by law, ONE HOUSE OF DERM, LLC is not responsible for loss, theft, or damage to personal property left unattended, except to the extent caused by the Practice's negligence or where responsibility cannot legally be disclaimed.

F. Balances & Collection

Any unpaid amount remains due on your account. The Practice may contact you by permitted methods, send statements, require payment before future services, or use a lawful collection process.

You agree to promptly notify the Practice of billing concerns. A chargeback should not be used as a substitute for first contacting the Practice to address a question or error.

The Practice may correct clerical or posting errors and will provide an itemized receipt upon request.

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ONE HOUSE OF DERM, LLC

Your Right to a Good Faith Estimate

 

Under federal law, health care providers must give patients who don't have insurance, or who are not using insurance, an estimate of the expected charges for medical items and services before those items or services are provided.

You Have the Right To:

• Receive a Good Faith Estimate of the total expected cost of any non-emergency items or services, including related costs such as medical tests, procedures, and products, upon request or when scheduling.

• Receive this estimate in writing at least 1 business day before your appointment, if scheduled at least 3 business days in advance (or at least 3 business days before, if scheduled 10+ business days in advance).

• Request a Good Faith Estimate at any time, even before scheduling — we will provide it in writing within 3 business days of your request.

If Your Bill Is Higher Than Expected

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

Please Remember

Keep a copy of your Good Faith Estimate. You will need it if you choose to dispute a bill. A Good Faith Estimate is not a contract and does not require you to obtain any items or services from us.

 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.