Financial Policy * Please understand that payment of your bill is part of this treatment and care. All Patients must complete our Patient Registration Form. We believe a good relationship is based on understanding and open communications. Our staff has been instructed to make every effort available to you to clarify any issues you might have with our insurance and what part is your responsibility. Every insurance is different, and every policy is different. We do our best to obtain your benefits before your appointment time, however it is also your responsibility to understand your benefits as well.                    

What Insurances Do You Accept? * We are participating providers with several insurance plans. We will file all these insurance claims as a convenience to the patient. A list of these insurances is available upon request. Please remember that insurance is a contract between the patient and the insurance company and ultimately the patient is responsible for payment in full. If our doctor is not listed in your plan’s network, you may be responsible for partial or full payment. If you are insured by a plan with which we have no prior arrangement, we will prepare and send the claim in for you on an unassigned basis. This means the insurance company may send the payment directly to you and therefore, our charges are due at the time of service. Due to the many insurance products out there, our staff cannot guarantee your eligibility and coverage. Be sure to check with your insurer’s member benefits department about services and physicians before your appointment. Many websites have erroneous information and do not guarantee coverage.                    

How May I Pay? * We accept cash, Care Credit, VISA, Mastercard, Discover and American Express. WE DO NOT ACCEPT CHECKS. Payment is due at the time of service. This includes copayments, co-insurance, deductibles and other fees that are not covered by your insurance policy. Our office does not allow payment plans after the service is performed. All “ESTIMATED” out of pocket expense is the patient’s responsibility before services are provided. Our billing office is staffed Monday -Friday 8 a.m. to 4:30 p.m. to answer any questions you might have regarding your account. Other payment plans or options may be available upon completion of financial statement analysis. Please contact our Billing Specialist for this information or when your billing address changes.                    

Do I need a Referral? * Eastern Shore Oral, Facial & Implant Surgery Center only accepts patients from General Dentists, Orthodontists, Periodontists, Prosthodontists, and Endodontists. If we do not have a referral for your visit, your appointment will be rescheduled.                    

What if My Child Needs to See the Physician? * A parent or legal guardian must accompany patients who are minors. This accompanying adult must have valid identification at time of service. A parent or legal guardian are the only ones allowed to give consent for treatment and will be responsible on the account. Court documentation is required if the parent is not the legal guardian. We will not be involved in separation/divorce disputes. The parent/guardian who accompanies the minor and signs the documents on behalf of the minor agrees to be solely responsible for the patient’s outstanding balance.                    

What is My Financial Responsibility for Services? * Your financial responsibility depends on a variety of factors. Claims that have not been paid in 45 days will automatically be billed to you and we can assist you in refiling your insurance at your request. Please make sure we have the correct information to file your insurance including (but not limited to): Social Security numbers, dates of birth, insurance company, policy and group numbers and patent address and telephone number. This can result in delay of payment.                    

When Is My Account Delinquent? * An account is considered past due 30 days following submission of the claim to the insurance company unless other arrangements have been made. Unpaid accounts beyond 45 days are considered and may be forwarded to our collection agency. We reserve the right to make those decisions on a case-by-case basis.                    

Are There Any Services Charges? * Keeping scheduled appointments is an important part of your health care. It allows your doctor or dentist to talk to you about your illnesses and what can be done to stay healthy. When you miss appointments, you also miss out on an opportunity to improve your health. Also, it takes an appointment away from other patients who may need it .There is a $50 No Show and/or Cancellation fee. We ask if you need to cancel your appointment to call at least 48 hours ahead of time so we may be able to see another patient in your place. Three (3) No Show appointments are grounds for patient discharge. However, we reserve the right to make exceptions to this policy.                    

Payment Due * Our office requires that all scheduled surgeries must be paid for by at least 50% of their co-insurance at the time of making the appointment. This allows us to reserve the allowed amount of time for your treatment. At your surgical appointment, we will issue a refund. If you do not show up for this appointment, you will automatically forfeit this deposit. If a refund is due, our office will refund the exact way the payment was made (if payment was made by credit/debit card, we will refund to that exact same card). If the amount is not able to be refunded back to the same card and a check has to be written, a 3% fee will be deducted from the amount refunded.                    

FMLA and Disability Forms * Completing forms such as FMLA and disability requires office staff time and time away from patient care for our doctor. We require prepayment for completing forms. If you need a form to be filled out or a letter summarizing your care here at Eastern Shore Oral, Facial & Implant Surgery Center, our charge is $25/per form.                    

Legal Fees * Any patient sent to collections will be responsible for collection fees. If a patient is taken to small claims court the patient will be responsible for all fees/charges.                    

Assignment Benefits * Please make sure you sign page 4 of the New Patient Demographics. This allows us to file your claims to your insurance company and they will make direct payment to us.                    

Phone Calls to the Physician * Our physician does not participate in telephone medicine; if you need to speak with the doctor, we can arrange an appointment for you.                    

Financial Policy * I have read, understand and agree with the above Financial Policy. I understand that charges not covered by my insurance company, as well as applicable co-payment, deductible and co-insurance are my responsibility. I consent to be contacted via phone calls, texts, emails and mail by Eastern Shore Oral, Facial & Implant Surgery Center or any 3rd party on behalf of the office working on an insurance claim or past due balance.                    

Insurance Benefits * I authorize my insurance benefits to be paid directly to Eastern Shore Oral, Facial & Implant Surgery Center.                    

Release of Medical Information * I authorize Eastern Shore Oral, Facial & Implant Surgery Center to release pertinent medical information to my insurance company when requested. I have read and understand the above policy.                    

Copy of Form * If you would like a copy of this form, please notify a staff member and we will be happy to oblige.