Due to Health Insurance Portability and Accountability Act (HIPAA) of 1996, the following information must be filled out by each patient annually.
Patient care is always our first priority. We take pride in delivering the finest care at a reasonable cost. For that reason it is important to have a good understanding regarding our office financial policies and your responsibilities.
Your insurance coverage is determined by your insurance plan, and it’s your insurance company that decides your benefits.
We are not responsible for any limitation in coverage that may be included in your plan. The financial obligation for our services rests on you.
As a courtesy to our patients we will file up to two insurance claims (dental-dental / medical-dental). If you have a secondary dental insurance that requires medical denial, only primary insurance will be filed and you will be responsible for the balance.
You can then file directly with your secondary insurance. We will gladly provide you with a copy of your itemized statement.
Please understand that even if you do have more than one medical and/or dental insurances, you might still have a deductible, co-insurance and/or co-pay obligation.
It is your responsibility to pay any denied or unpaid balance in full.
PLEASE READ CAREFULLY
ATTENTION PATIENTS WITH OUT OF NETWORK INSURANCES
If our providers are NOT in-network with your insurance plan, all procedures will be processed by your insurance as out-of-network.
This means you will have to pay based on out-of-network coverage % and the explanation of benefits (EOB) from your insurance company won’t necessarily match your financial responsibility with our office.
Even if we are informed that you have out-of-network benefits under your insurance company, certain types of plans will not pay any money if the patient requests and seeks services from a non participant provider.
It is your responsibility to confirm this information with your insurance provider.
ATTENTION MEDICARE PATIENTS
We are not MEDICARE providers, for that reason we can not file claims to supplemental medical insurance for patients covered under Medicare.
If you have a separate dental coverage, and your procedure is considered dental, we will verify your insurance benefits and quote our services accordingly.
If a Medicare explanation of benefits is required for any dental or medical procedures, patient will be responsible for the full balance.
SELF PAY PATIENTS
Your treatment plan estimate will be valid for 60 days from the day you sign your estimate.
A $50.00 surgery scheduling fee will be charged when a patient schedules surgery. This fee will be applied to patient’s balance once insurance is processed.
If patient does not comply with our cancellation policy, the $50.00 surgery scheduling fee will be forfeited. For surgeries that require three or more hours, a customized schedule fee will be requested at the time of scheduling.
Because your schedule may change, if your appointment is more than two months in the future, we will need to verify that you want to keep that appointment closer to surgery. We will need to confirm your appointment 7-14 days prior to surgery. We will try to contact you during this time frame. If we receive no call or reply from you within one week of surgery, the appointment will be cancelled and there will be no refund of your scheduling fee. If we are able to contact you but the original surgery date no longer works, our scheduling fee can be refunded or applied to another appointment date.
If you must cancel or reschedule your surgery, please allow at least 48 hours notice.
There will be a late cancellation charge that equals your scheduling fee, if you no-show, cancel or reschedule your surgery with less that 48 hours notice.
If proper notice is not given or you simply do not show up for your appointment, and you would like to re-schedule your procedure, you will be required to pay your entire estimated amount for the procedure prior to being placed back on the surgery schedule.
For your convenience, we accept Visa, MasterCard, Discover, debit card (Visa or MasterCard logo), money orders and cash.
If one of these are not an option for you, you can apply for Care Credit, which is a third party payment plan alternative.
Personal checks or American Express, won’t be accepted as a method of payment.
If patient pays a final balance by mailing a check, and check is returned as “insufficient funds”, a fee of $25 will be added to your balance.
A patient's account remains due and payable within 30 days after the insurance processes your claim.
If it becomes apparent that the patient does not intend to satisfy their unpaid balance, a collection agency may be employed to pursue collection of the account.
The patient will be charged and held responsible for all collection fees incurred by Alliance Oral & Maxillofacial Surgery in collecting the debt. Those charges will be automatically added to the patient's account.
Once your account is transfer to a collection agency, our office won’t be able to process any payments.
I have read and understand my financial obligations as a patient / authorized representative.
I acknowledge that I am fully responsible for providing correct insurance information and payment for all services not covered by my insurance company for any reason.
COVID-19 PANDEMIC PATIENT DISCLOSURES
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19, also known as "Coronavirus," pandemic.
A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19.
Please disclose to us any condition that compromises your immune system and understand that such disclosures may impact treatment decisions.
People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. These symptoms may appear 2-14 days after exposure to the virus.
It is important that you disclose any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history.
By signing this document, I acknowledge that the answers I have provided above are true and accurate.