Designation of Financial Responsibility
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. Although separate entities, your dental office is authorized to provide personal information to us as it pertains to your anesthesia account with Bay Anesthesia, and vice versa.
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 (after your balance has been paid in full) that you may 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 with any questions regarding your coverage, their payment policies, and reimbursement procedures.
Once your deposit has been paid, your appointment will be confirmed with our office. The remaining balance is due in full on the day of the procedure, and will be automatically charged to the card on file on or after treatment is completed, until the balance is paid in full.
I certify that I have read, understood, and acknowledged the above information. By completing the below information, I also understand and acknowledge my financial responsibility for the anesthesia services provided by Bay Anesthesia Group.