INSURANCE

Your insurance policy is a contract between you and your insurance company. It is the responsibility of the insured / subscriber to check with their employer or insurance company regarding the benefits for services provided in our office. Since our office works with so many insurance plans, it is impossible for us to know the details of your plan. Be aware that some or all of the procedures may not be covered.

Some insurance companies require a referral and/or prior authorization for optimal coverage. It is the responsibility of the insured/subscriber to acquire the proper referral. Our office will submit a prior authorization to your insurance company upon request (please allow 4-6 weeks for insurance processing).

I hereby authorize, assign, transfer payment of services otherwise payable to me, directly to Midwest Oral & Maxillofacial Surgery, PA. I authorize the release of x-rays and any information regarding examination or treatment.

I agree to be responsible for all charges for services and materials not paid by my plan.

FINANCIAL ARRANGEMENTS

Our practice is committed to providing the best treatment for our patients. Please ask if you have questions or concerns regarding fees, financial policy or your responsibilities.

1. All patients must sign and accept this form prior to seeing the doctor.
2. IF YOU DO NOT HAVE INSURANCE, PAYMENT IS DUE IN FULL THE DAY OF SERVICE.
3. If you have insurance, it is your responsibility to determine if our office is a provider for your specific insurance. And while your claim is being processed a down payment is required.
4. After your insurance has sent reimbursement to our office, you will receive a final bill showing your remaining balance owed to us or the amount to be refunded to you.
5. All insurance denials and untimely insurance payments must be paid within thirty days (30) days from the date of service. Account balances unpaid after 30 days will be assessed a finance charge of 1 1/2% (18% APR). All accounts unpaid after ninety days will be turned over to a collection attorney unless other payment arrangements have been made. All collection and attorney fees are your responsibility. If untimely insurance payments are received while the account is in collections, the responsible party will be liable for all collection fees before any refund will be issued.

WE ACCEPT CASH, PERSONAL CHECKS, VISA, MASTERCARD, & DISCOVER

I have read and understand the financial policy of Midwest Oral and Maxillofacial Surgery, PA and by signing below I agree to all the terms of this financial policy.