Financial Agreement
Patient / Parent / Legal Guardian Agreement
I have read, understand, and agree with the estimate of fees of $700 for the first hour of anesthesia and $150 every 15 minutes thereafter. I agree that Pathways Anesthesia can charge me a fee equal to but not greater than the outstanding balance (plus recovery fees if necessary) to recover the outstanding balance of services rendered.
Pathways Anesthesia, LLC does not bill insurance companies directly and does not accept insurance-based reimbursement for payment. I understand that it is my responsibility to check insurance benefits prior to scheduling.
I understand that after services are provided, I will receive a Final Bill that I may submit to my insurance company for possible out-of-network reimbursement. I understand that reimbursement is not guaranteed and depends on the terms of my insurance plan.
I acknowledge and agree:
- Pathways Anesthesia, LLC does not accept insurance.
- A non-refundable deposit of $700 is required no later than 72-hours prior to my scheduled appointment and will be applied to my final anesthesia balance.
- Full payment is due on the day of service prior to discharge, regardless of insurance coverage or reimbursement.
- Accepted payment methods are credit card and cash only. No checks are accepted.
- Anesthesia fees are separate from dental treatment fees, which are billed directly by the dental office.
- Anesthesia fees are calculated based on the dentist’s actual procedure time plus 30 additional minutes for anesthesia induction and recovery.
By electronically signing below, I confirm that I have reviewed, understand, and agree to all insurance and payment policies of Pathways Anesthesia, LLC.