MOS Financial and Appointment Policy

AUTHORIZATION

I certify that I have read and I understand the medical questions on the registration. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his staff, responsible for any errors or omissions that I have made in the completion my registration/medical forms.

I authorize my surgeon and his designated staff, to perform an oral and maxillofacial examination and treatment. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination and treatment. In addition, I authorize the release of any information acquired during my examination and treatment to my other doctors and/or insurance carriers.

FINANCIAL POLICY

Accordingly, prior to receiving treatment and services, you agree to the following: As your dental care provider our relationship is with you, the patient, not your insurance company. We bill your insurance company as a service and do our best to collect payment from them; however, any balance not covered by insurance is the patient’s responsibility.

An insurance estimate will be provided to you upon treatment being presented. This is an estimate and not a guarantee of payment from your insurance company. We do our best to present you with the most accurate estimate possible.

A pre-treatment estimate will be sent when possible; however, this is also an estimate from the insurance company and is not a guarantee of payment.

You understand and agree that you are responsible for paying estimated co-pays, deductibles, and co-insurance payments at the time of appointment. We accept cash, checks, all major credit/debit cards, HSA cards, and several third party lenders such as Care Credit and Proceed Finance.

If you have a balance on your account that is not satisfied within 120 days of date of-service, your account will be sent to a collection agency along with collection, attorney, or court costs associated with collecting this debt.

All returned checks are subject to a $30 returned check fee.

APPOINTMENT POLICY

 You understand and agree that a $50 fee will be added to your account for any missed or cancelled appointments without the required 24- hour notice. This $50 fee must be paid prior to rescheduling your next appointment.