Tri-State Oral and Maxillofacial Surgery
Authorization and Acknowledgement of Provided Forms
(this form may be printed or emailed on request)
OFFICE VISIT
Please provide the following for every appointment: Government Issued Photo ID, Insurance Card, Co-Pay, Referral and X-ray from general dentist, if obtained. Anyone under the age of 18 must have a parent or legal guardian accompany them with their photo ID. For court appointed guardians and power of attorneys, we must have all legal documentation.
INSURANCE
As a courtesy to you, we will be happy to file your DENTAL insurance claims for you. We will first file the claim through a secure electronic processing center. If no response is received from your dental insurance company after 60 days, we will then file the claim through paper mail. If your dental insurance company still does not respond within 30 days of the claim, the balance will then become your (patient) responsibility. We will provide you with any and all information necessary for you to obtain payment from your carrier; however, the balance must be paid to us immediately. All unpaid balances will be subject to a 1.5% interest fee monthly. All checks that are returned from your bank will receive a NSF charge of $30.00 per check.
PAYMENT OPTIONS
We accept Visa, MasterCard, American Express, Discover, checks and cash for payment. Payment in full is expected at the time of service. If you have insurance, we will collect your percentage at the time of service. We also have a financing option available through Care Credit and can assist you in completing the paperwork / application. Please see the front office staff for further information.
We will do our best to work with you if your dental insurance does not pay the expected amount. However, if we do not receive cooperation, we turn your account over to our outside collections representatives. If your account is released, you will be responsible for all fees incurred by the collection agency and all applicable court fees.
INITIAL APPOINTMENT FEES
Routinely, the fee for your initial consultation will be $230.00 (cost of exam & x-ray).
NOTICE OF PRIVACY POLICIES (HIPAA)
Our Notice of Privacy Practices (HIPAA) is posted at the reception desk. If you would like a copy for your own files, please feel free to request one.
I have read the policies as outlined by Tri-State Oral and Maxillofacial Surgery. I understand that any and all charges obtained by me, are my responsibility and agree to pay all fees associated with my account. I also understand that If my account becomes past due, I may be subject to agency fees and court costs. By signing below, I indicate that I have read and understand, and/or received a copy of this office’s Notice of Privacy Practices (HIPAA). I give consent to Tri-State Oral and Maxillofacial Surgery to obtain information needed to diagnose and treat my condition. My signature acknowledges that I have read the given forms, asked questions, and agree to the content described. I also understand that I may request copies of any form I have signed.
**IF YOU ARE HERE FOR SURGERY, YOUR ESCORT MUST REMAIN HERE THE ENTIRE LENGTH OF YOUR APPOINTMENT. IF THEY CHOOSE TO WAIT IN THEIR CAR OR OUTSIDE ON THE PREMISES, A WORKING CELL PHONE NUMBER MUST BE PROVIDED TO THE FRONT DESK!**
Please proceed to the SIGNATURE page to complete your form.