Forms

Health history - please complete and bring with you to your appointment.

Consent for treatment - this will be filled out at your appointment.

Photography consent - this will be filled out at your appointment.

Payment and Appointment Time Understading - this will be filled out at your appointment.

Aftercare instructions - you will be provided these at your appointment  

Payment receipt for your health insurance company for POSSIBLE reimbursement for Breast Cancer Reconstruction tattoos ONLY. Permanent makeup and areola cosmetic tattooing are not covered by insurance. 

Breast Cancer Reconstruction patients PLEASE READ THIS ENTIRE PAGE!

 

The Women’s Health and Cancer Rights Act of 1998 requires insurance to cover postmastectomy reconstruction, including areola/nipple tattooing. Insurance may reimburse some of the cost of procedures. We can provide you with a receipt to turn into your insurance provider for POSSIBLE reimbursement. You must turn the receipt in with a prescription from your physician’s office for the tattoo including medically appropriate diagnosis & CPT  codes on the Rx itself. It is suggested that you check with your provider prior to your procedure to be sure this service is covered. 

Here is a link to the US Department of Labor’s details on insurance coverage for women post breast cancer.  http://www.dol.gov/ebsa/Publications/whcra.html

 

                  Insurance...the ugly truth

 

Unfortunately,  insurance covers tattoos done in physician offices by unskilled staff with terrible results. UGLY results.  They are billed astronomically to your insurance and every repeated application is as well. It's not unheard of to repeat this 3 or even 4 times in the doctor's office. I know, because I did exactly that for almost a decade in a plastic surgery office. This is not something I am proud of, knowing what I know now. It's highly likely these visits won't occur in your reconstructive year so this high amount hits your deductable/coinsurance. Many times these ladies pay way more when this process has occurred than an out of pocket payment for service to a specialized artist…and leave the doctor's office with a less than desirable result. About 25% of my clients require corrective tattooing for specifically this reason. Please see “corrective tattooing” in the gallery for examples.

                 

      I do suggest at least trying for reimbursement ...

At minimum, they usually require the fllowing turned in:

1.                A prescription from your doctor with ICD10 and CPT codes-from you

2.               A claim reimbursement form found on their specific website- from you

3.               Receipt of payment which is paid to me on day of service-from you

4.               Letter of medical necessity (which I can provide)- from me

5.               My procedure note documentation- from me

6.               Your health history form filled out at your visit- from me

7.              * If they require a prior authorization- I do not do them. You may try to do it yourself but you will need the codes on your prescription from your doctor to provide to the insurance company. (see #1)

             I cannot stress this part enough….

I will provide you with paperwork to turn in for POSSIBLE insurance reimbursement. I NEVER guarantee your insurance company will reimburse you or to what amount. I am NOT a participating provider with ANY insurance company so, I'm considered out of network. So, if you have NO out of network benefits, they will not cover this procedure with me.  I also do NOT do any prior authorizations with insurance because I am not a participating provider with any insurance company.

It is your responsibility to call and find out what they require for your plan. After your tattoo, I am happy to send in my procedure documentation and a letter written on your behalf to your insurance company if  requested, to aid in your reimbursement.