Your insurance policy is a contract between you and your insurance company. It is the responsibility of the insured / subscriber to check with their employer or insurance company regarding the benefits for services provided in our office. Since our office works with so many insurance plans, it is impossible for us to know the details of your plan. Be aware that some or all of the procedures may not be covered.
Some insurance companies require a referral and/or prior authorization for optimal coverage. It is the responsibility of the insured/subscriber to acquire the proper referral. Our office will submit a prior authorization to your insurance company upon request (please allow 4-6 weeks for insurance processing).
I hereby authorize, assign, transfer payment of services otherwise payable to me, directly to Midwest Oral & Maxillofacial Surgery, PA. I authorize the release of x-rays and any information regarding examination or treatment.
I agree to be responsible for all charges for services and materials not paid by my plan.