Office Policy
No Cell Phones in Patient Care Areas
Due to federal HIPAA Confidentiality Regulations, cell phones are not permitted in patient care areas. This includes:
- Phone calls
- Photos
- Videotaping
- Audio recordings
Thank you for your cooperation and
respect for our patients’ and employees’ privacy.
Financial Policy
Thank you for choosing our practice to serve your Oral Surgery and Dental needs. Please read the following carefully. Your signature below indicates your understanding and acceptance of our financial policy.
- Full payment is due at the time of service unless arrangements have been made prior to the start of any treatment.
- Insurance balances are ultimately the patient’s obligation. We will file most primary insurances as a courtesy. However, insurances balance which are not paid within 60 days may be billed to you. Please keep your walk out statements and follow up with your insurance carrier to ensure prompt payment.
- Some of your treatment many not be covered by your insurance company. The fee for such charges will be your responsibility.
- Major services may require a deposit equal to at least one half of the estimated patient portion at the time the appointment is made.
- Patients are asked to confirm their appointments at least 48 hours in advance by directly contacting our office or by responding to our confirmation contact.
- You will need to provide notice of 48 hours for appointment time changes or cancellations to avoid broken appointment fee of $50-$300.
- There will be a fee of $30.00 for any checks returned as Non-Sufficient Funds (NSF).
- Patients balances that go unpaid for 30 days or more may incur one or more of the following charges:
Interest charges of 1.5% per month of 18% APR Collections fees (up to 42% of the full balance), Legal fees for collection services.
Signature of Patient or Guardian
Print Name
Date
