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. We do not accept insurance as payment in full, but will handle the submission of all claims as a courtesy to you. We request that all accounts be paid in full within 30 days, unless other specific arrangements have been made prior to date of service.
Statements are mailed to all patients (regardless of insurance coverage). All accounts over 90 days old will have a service charge added to the unpaid balance each month. Missed monthly payments may be subjected to a $15 late fee.
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 ofthis form. Contract benefits will be paid directly to the provider. The patient will pay their percentage on the day of service (not less than 20%). The balance will be due in 30 days by either the insurance company or the patient.
4) Appointments cancelled with less than 24 hours notice map be subiect to a $100 fee!
5) A $25 dollar returned check fee will be assessed on any NSF checks written on your account.