Financial Policy

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy that we require you to read and sign prior to any treatment. All patients must complete our patient information and insurance information before seeing the doctor. You as the patient and/or responsible party should be aware of your insurance coverage.

Regarding Indemnity Insurance

We may accept assignment of insurance benefits (that is you agree to have us file a claim on your behalf with the insurance carrier). However, we do require a payment time of services. The balance is your responsibility whether your insurance company pays or not. We can only bill your insurance company when the correct information is presented to us. Your insurance policy is a contract between you and your insurance company. As your chosen healthcare provider, we are nota party to that contract. In the event we do not accept assignment of benefits we require full payment at time of services. If your insurance company has not paid your account in 120 days, the balance will be your responsibility. In the event that your insurance company pays, we will refund you any amount due to you. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under the Medicare Program and/or other medical insurance.

Regarding Self Insured Employer Plans

Self insured plans may be indemnity or managed care. In the event you are covered under an indemnity type self insured plan, we may accept assignment of insurance benefits (that is you agree to have us file a claim on your behalf with your insurance carrier). However, we do require a payment at time of service. The balance is your responsibility whether your insurance plan pays or not. We cannot bill t=your insurance company unless we have the most updated insurance information on file. Your insurance policy is a contract between you and your insurance provider, as your chosen healthcare provider, we are not a party to that contract. In the event we do not accept assignment of benefits we require that you pay your balance at time of services. If your insurance company has not paid your account within 120 days, you are responsible for the balance and any late fees.

Regarding Managed Care Contracts

We are contracted with a number of managed care companies. If you are seeing us a s a managed care patient under a contract in which we are a participating provider, you will be charged in accordance with the terms of our contract with the managed care company. All co-pays and deductibles are required to be paid prior to treatment. In addition, please understand that you may be liable to pay for any services you requested that are not covered under our contract. In the event that your insurance coverage changes to a plan in which we are not a participating provider, refer to the paragraph above.

Usual and Customary Rates

Our practice is committed to providing the best treatment for our patients. We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Adult Patients

Adult patients are responsible for full payment at time of service.

Minor Patients

The adult accompanying a minor and the parent (or guardian of the minor) are responsible for full payment. No surgery can be done on a minor unless a consenting adult is present.

Missed Appointments

Please help us serve you better by keeping your schedule appoinment. Unless canceled at least 24 hours in advance our policy is to bill for a normal office visit.

Late Fee

A late fee of $25.00 is applied to all accounts not paid in full 15 days from statement date.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns.

Procedure Notes

You or your family member is cuurently scheduled for oral sugery/extractions in our office. Please take a few moments to review the following information concerning the upcoming scheduled preocedure

If you will be going to sleep (sedation with I.V), please folloow these guidelines:

• DO NOT eat or drink anything (including water) eight (8) hours prior to surgery.
• Arrange to have transporation home and do not drive for 24 hours after surgery.
• Wear loose-fitting, comfortable clothing to the appointment.
• Contact lenses cannot be worn during the surgery. Please wear glasses or bring your contact carrying case.
• Do not wear any jewelry or fingernail polish.
• Do not wear sandals or flip flops

Pre-medications need to be taken for hip/knee replacement or heart problems.

If you are taking blood thinners or have any medical conditions, please contact our office so you can receive proper medical care/ medical clearance from your specialist if required.

At the time of surgery, a deposit will be required. It is important that you are familiar with your dental/medical insurance benefits regarding this procedure. You will be responsible for your financial portion the day of surgery. If you do not have any insurance the entire amount is due unless prior arrangement have been made with your office. We accept cash, check, MasterCard, Visa, Discover, and American Express. We can also provide you with information regarding dental financing companies.

Please bring your insurance cards or forms to this appointment. It should have the insrance company's mailing address on it. We will make a photocopy of it to be put in your chart. This is the patient's responsibilty to provide the office with proper medical/dental information the day of your appointment.

Please complete the enclosed patient registration and medical history forms and bring them with you to the appointment. You may also fax these forms into our office for your convenience. Please do not mail this information back to our office to avoid the risk of being lost in the mail. If you should need to cancel your appointment, please contact our office as soon as possible.