Pediatric - Financial Policy

Financial Policy

Welcome to Bay Anesthesia Group! We are honored that you have entrusted us to provide your child's anesthesia treatment. Bay Anesthesia's group of Anesthesiologists specialize in providing hospital quality advanced anesthesia services from the comfort of your own dental office. Please read the information below which outlines your financial obligation for the day of your child's procedure. Should you have any questions, please contact our office directly at 650-282-4171. We look forward to speaking with you!

Payment for Services:

Bay Anesthesia is a private "Fee-for-Service" company and payment is due in full at the time services are rendered. We are a completely separate entity from your dentist and all related fees, operative times and/or orders are separately charged and billed.

Estimated Fees in the amount of $ are due in order to secure your scheduled appointment time. ($300 of this payment is considered your Non-Refundable DEPOSIT.) As long as you arrive on time, and have followed all eating & drinking guidelines, your full payment will be applied to your total fee. Payment may be completed on our website at https://bayanesthesiagroup.com by selecting the "In Office Anesthesia Payment" option, entering the amount listed above, and proceeding with payment. (Please be sure to include the Patient Name & DOB in the "description" field). Any additional balance is due on the day of the procedure, and will be automatically charged to this same card. If the estimated fee paid exceeds the total due, a refund will be processed back to your original payment method, upon completion of treatment.

By signing below, ("Credit Card Payment Authorization"), you authorize Bay Anesthesia to submit payment to your credit card for your Estimated Fee and any remaining balance due on or after the date of service, until the balance is paid in full.
We accept all major Credit/Debit cards, Health Savings Account cards (HSA), Flex Spending Account cards (FSA), Care Credit (6-mos interest free term), or Cash in the office on the day of your appointment.

Insurance:

Bay Anesthesia Group does NOT accept insurance as payment for services. Upon request, we can provide you with an itemized receipt and a copy of the anesthesia record, from the day of treatment. You may use these documents to submit directly to your insurance company for potential Out of Network reimbursement. We do not guarantee that you will receive reimbursement from your insurance company. Please contact your carrier directly, for any questions regarding your coverage, their payment policies, and reimbursement procedures.
Additionally, I attest that I am not a TriCare patient or TriCare beneficiary.

I certify that I have read, understood, and acknowledged receipt of a copy of the above Financial Policy. I also understand and acknowledge my financial responsibility for the anesthesia services provided by Bay Anesthesia Group.

Patient Name

Date of Service

PatientGuardian Signature

Date

Credit Card Payment Authorization

Cardholder Name*

Card Number.

Expiration Date*

CVV*

Drivers License*

Exp*

Address Zip Code*

Cardholder Signature*

Date*

160 W. Foothill Pkwy Ste 105 #244 Corona, CA 92882