HIPAA Privacy Authorization Form

Notice of Information Practices:

I understand that Skin + Tonic may use or disclose my personal health information (PHI) for the purposes of carrying out treatment, obtaining payment, evaluating the quality of services provided, and any administrative operations related to treatment or payment. I have the right to restrict how my personal health information is used and disclosed for treatment, payment, and administrative operations if I notify the practice in writing and prior to treatment. Requests for restriction will be considered on a case-by-case basis, and the practice is not obligated to agree to such requests. I have the right to revoke this consent at any time by notifying the practice in writing.

Authorization for Release of PHI:

By way of signing the policy acknowledgements, I hereby authorize one or all of the designated parties below to request and receive the release of any PHI regarding my treatment, payment, or administrative operations related to treatment or payment. I understand that the identity of designated parties must be verified before the release of any information.

Privacy Policy

Collection Of Your Personal Information:

Skin + Tonic collects personally identifiable information, such as your email address, name, home or work address, credit cards for payment requirements or telephone. Additionally, information about your computer hardware and software is automatically collected, including your IP address, browser type, domain names, access times, and referring website addresses. This information is used for the operation of the service, to maintain service quality, and to provide general statistics regarding website usage on a HIPPA compliant server.

Use Of Your Personal Information:

Skin + Tonic uses your personal information to operate the website, deliver requested services, and inform you of other products, promotions, or services. Your information may be shared with trusted partners for specific purposes, and these partners are obligated to maintain the confidentiality of your information. Sensitive personal information will not be disclosed without your explicit consent, except when required by law.

Use Of Cookies:

The website may use “cookies” to personalize your online experience. Cookies are text files placed on your hard disk by a web page server, and they cannot run programs or deliver viruses. You can configure your browser to accept or reject cookies.

Security of your Personal Information:

Skin + Tonic secures your personal information from unauthorized access, use, or disclosure. It is stored on secure servers in a controlled, secure environment.

Changes to this Statement:

Skin + Tonic may update this Statement of Privacy to reflect company and customer feedback. Periodically reviewing this statement is encouraged to stay informed about how your information is protected.

Contact Information:

For questions or concerns about this Privacy Policy, contact Skin + Tonic at 113 W. Grand River Ave, Brighton, Michigan 48116, or by phone at 810-522-4799 or skinandtonic.brighton@gmail.com.

Credit Card on File:

Skin + Tonic requires a credit card on file for all scheduled appointments. Should the credit card on file become inactive or be declined for payments to on account charges, all services will be suspended until payment is rendered in full. Should a client have 2 violations they will be subject to management approval and pre payment for services required.

Cancellation, Reschedule, and No Show Policy

Cancellation and Reschedule:

Clients are required to cancel or reschedule appointments 48 hours before the scheduled time. A $50 no show/reschedule/late cancellation fee will be assessed by way of credit card on file. By Signing for consent for treatment and policy acknowledgements, the client is authorizing this charge and waives any rights to dispute this fee.

No Show Policy:

Clients who do not show up for a scheduled appointment will be charged a non-refundable $50 fee via the credit card on file. Clients with previous no-show history may be subject to prepayment for future appointments.

Late Arrivals:

Clients are encouraged to arrive 5 minutes prior to the appointment to complete paperwork. Arrivals more then 15 mins late, may lead to rescheduling, at the discretion of administration and a non refundable $50 fee for rescheduling.

Payment Agreement Policies

A 5% Professional Fee is added to all Payment Plans.

1. All transactions using Care Credit or Cherry as payment method 

2. Remaining Balances on Inhouse Financing 

As well as:

1. 3% per day on all Late Payments on Account Balances or Membership Auto Deductions 

2. 3.5% on all other Credit Card Transactions 

Refund/Exchange Policy:

No refunds or exchanges are offered for any reason on any service or product purchased. Exceptions may be considered for extenuating circumstances, and are subject to management approval. Please submit in writing with an explanation of the request and allow 30 days for a determination. This determination is final and not eligible for appeal. CLients waive their right for dispute through any means of payment ie: Credit Card, 3rd Party payers and or any other means of payment by way of signing consent for treatment.

Laser Hair Removal Policy

Laser Hair Removal Packages:

Packages consist of 8 treatments, striving for a 70-90% reduction in hair growth, thickness and pigmentation. Further information on Laser Hair Reduction is contained within the Informed Consent. Maintenance Treatments are offered for any area previously purchased at a rate of $99 per hour per area after the 8 treatments are rendered. It is the clients responsibility to schedule their appointments within the appropriate time frame. THis is a requirement to obtain optimal results.

Portal Policy

Texting Line:

No private chart information is shared through this communication. Any pertinent info or photos are transferred into the specific clients HIPAA compliant profile for documentation and are deleted from the text feed daily. By accepting our policies you are agreeing to this portal of communication.

Aesthetic Portal:

Clients are provided with HIPAA-compliant portal access for reviewing consents, pre and post instructions, scheduling, and communication with staff. Information in the portal is not shared with third parties unless required by law. 

You may access your personal HIPAA compliant charting through our BOOK NOW tab. You will be prompted to create a log in and password for security. Please contact staff if you need to change or have forgotten your password for assistance.

Jan Marini and Epionce

Skin Care Systems:

Clients authorize the entry of their data to secure custom purchasing accounts for skin care products and grant access to educational information on the website. Opting out requires written notice within 7 days of the first treatment.

Membership Policies

Website Access:

Locked website access requires membership inquiry and compliance with HIPAA regulations. Membership dues can be canceled with 30 days’ written notice. Please note that all membership discounts cease with cancelation of said membership effective the same day of cancelation. Any balance on account will remain for use and is not eligible for refunds.

Photo Consent

Before and After Photos:

All treatments are subject to before and after photos taken by staff, stored in a HIPAA-compliant system. Clients refusing photos may face cancellation of treatments without refund. Any photos submitted via the texting line are loaded to clients HIPPA compliant charts and removed from texting portal.

Injectable Policy

Dermal Filler Appointments:

Derma filler consults and appointments require a $100 non-refundable deposit.

Neurotoxins:

Neurotoxin dosing adjustments are offered at a discounted rate if completed within 10 days of the initial treatment. Late follow-ups will be subject to full price for any dose adjustments requested.

Note: The provided information is a summary. It’s recommended to review the original document for detailed and accurate information.