We are pleased that you have chosen our office for your oral surgery care. It is our goal to make this a comfortable and positive experience for you. Our financial policy is designed so that you and our office will have a clear understanding of your financial commitments prior to surgery, and so we can have an agreement of terms of payment that will work for both of us.
The patient or parent/guardian is responsible for this account, regardless of insurance coverage. Our treatment coordinator will be happy to work with you to determine the extent of your insurance coverage. We do not accept insurance as payment in full, but will handle the submission of all claims as a courtesy to you. You will be required to pay any deductibles, co-payments, and fees on or before your surgical appointment. If you do not have insurance coverage, payment is due in full on the day of service.
1) Payment in full on the day of service. We accept cash, check or Visa/Mastercard, Discover.
2) We also offer payment plans through CareCredit. Click here to submit an application.
3) Verified insurance coverage: Authorized release of any information relating to my claim, to the insurance carrier(s), listed on the reverse of this form. Contract benefits will be paid directly to the provider. The patient will pay estimated portion on the day of service. The balance will be due in 30 days by either the insurance company or the patient.
4) A $35 dollar returned check fee will be assessed on any NSF checks written on your account.