Thank you for choosing my practice for your oral surgery needs. I am committed to providing you with the best overall possible care. This includes proper and timely handling and filing of your insurance claims.
However, you must realize your insurance is a contract between you, your employer and the insurance company. It is your responsibility to furnish complete insurance information at the time of your appointment. Without the complete insurance information we will be unable to properly file your claim and therefore, you will be responsible for the entire bill at the time of your appointment. Our office will do everything possible to assist you and your insurance company in processing your claim.
Insurance companies pay a percentage of the “Usual and Customary” charges. These fees do not always match the doctor’s fees; therefore, we will provide you with an estimate of what the insurance will cover and what your surgery deposit will be. This deposit will be due the day of surgery. The surgery deposit is only an ESTIMATE. If your insurance pays more than quoted to you, we automatically refund to you any over payment. If the insurance pays less, you will be billed for the remaining balance.
Regardless of insurance coverage, account balances which are 90 days or over from the date of service, payment will be expected in full by the person who signed financial responsibility for the account. If you have any questions regarding this policy, please feel free to speak with us.
In consideration of the services provided to the patient, I/we hereby guarantee payment in full of the patient’s account within thirty (30) days from payment of insurance. I/we agree that in the event of default in payment, reasonable collection agency fees equal to thirty (30%) percent of the delinquent balance, and/or reasonable attorney fees shall be added to the amount due on the account, plus any applicable court costs.
CANCELLATION POLICY: To avoid a $50.00 charge, a 48-hour notice is required for cancellation of your scheduled appointment.