I understand that an insurance claim form will be submitted electronically by the office. I am aware I will receive one of two forms, either a “claim acknowledgement form” or an “explanation of benefits” form. I have been informed that the predetermination is just an estimate and that the final fee will be determined at the time of surgery based on the difficulty of surgery. I understand that it is my responsibility to cover the costs of all treatment rendered by the oral surgeon, and that I am financially responsible for the full amount of the account. I understand that any concerns regarding the fees that the insurance company may or may not cover must be discussed with the surgeon prior to the surgery date.

I will be given a written estimate and am aware that it is just an estimate. I understand that it is my responsibility to cover the costs of all treatment rendered by the oral surgeon, and that I am financially responsible for the full amount of the account.

Our office does not extra bill or bill for balances not paid under the government assisted plan. We do bill the patient for services not covered and not paid for under the plan. Payment must be made at the time services are performed.