Pediatric Patients Financial Agreement and Policy

By signing below I identify myself as the parent or guardian (type in above) of the patient named above, hereby acknowledge, guarantee, and agree to bear the full financial responsibility for the payment of all anesthesia services to be provided by Dr. Reza Izadi. I further understand that by signing this document, I am agreeing to pay Dr. Izadi his full fee for anesthesia services on the day such services are rendered as Advanced Dental Anesthesia PLLC (Safe Dental Sedation) hereon also referred to as “ the company” . If the anesthesia time exceeds the estimate that I was previously provided, I hereby agree that I will be responsible for said additional fee, and in fact, pay said sum on the day the services are actually rendered. If the anesthesia time is less than the estimated time, the patient/parent/guardian will be charged based on the actual anesthesia time.

I understand that $300.00 of the payment I have made is considered to be a deposit and is non-refundable in an effort to make certain that the patient complies with the instructions given prior to the anesthesia appointment, and to reserve the anesthesiologist’s time. 

I understand that the company is a "Fee for Service” practice and that no insurances are accepted. Terms such as “in-network” or “out of network” provider do not apply to the company as we do not engage in any form of billing of your medical insurance company for reimbursement of our services provided to you. You are solely responsible for our fees.

I agree to allow my dental office to provide Advanced Dental Anesthesia PLLC ( Safe Dental Sedation ) with copies of my Drivers Licenses or additional personal information in case of outstanding unpaid balances.

I understand that the company is a “fee-for-service'' practice, and no billing is done by the company to your company insurance . Advanced dental anesthesia PLLC  will not contact or email or respond to any requests to communicate with your medical insurance company in any way. 

I have read and agree with declarations in “Exhibit A” on this document. 

I have read and agree with the paragraph on this document titled “Fee Schedule Policies and Insurance Disclosure’. 

I have read and agree with the paragraph on this document titled “Explanation of Anesthesia Times and Fees”

I have read and agree with the paragraph on this document titled “Cancellation Policy”

Fee Schedule Policies and Insurance Disclosure

Advanced Dental Anesthesia PLLC is a “Fee for service” boutique medical service.  The fees include the costs of medications, equipment and the anesthesiologist’s professional fees. ADA PLLC will not accept insurance payments of any kind, however you will be provided with a record of payment for services rendered that you can send to your medical insurance for possible reimbursement or partial reimbursement.  There is no guarantee of this payment from your insurance. You should contact your medical  insurance ( not dental insurance ) to confirm this and get their specific details for possible pre-approval. This reimbursement should not be assumed and it remains the responsibility of the patient or the payment guarantor to pay for the anesthesia fees.  It is the patient's responsibility to work out any insurance reimbursement details with their insurance. Please see the PDF called Pediatric Insurance Guidance  for more information. Any  unreimbursed portion might be tax deductible as a medical expense.  Please consult a tax advisor.

Explanation of Anesthesia Times and Fees

The fees are shown in the table below.

Anesthesia time is the procedure time plus typically a varying 20-35 minutes which consists of the anesthesia start and recovery times. Anesthesia time starts with the patient entering the procedure room and ends after release from recovery by the anesthesiologist. A Prepayment of $300.00 is required 1 week in advance and is nonrefundable. 

Example of fees ( Anesthesia time = Procedure time + Anesthesia Start + Recovery Time )

Total hours  ( Anesthesia Time )                         Fees
Fee
0-60 minutes (Non Prorated).                           $ 895.00
60-75 minutes                                                 $ 1095.00
75-90 minutes                                                 $ 1295.00
90-105 minutes                                               $ 1495.00
106 minutes to 2 hours                                   $ 1595.00

Every hour after billed at $600/hr in 15 minutes increments 
Or $150 every 15  minutes 

Exhibit “A”

1) The party executing this Agreement hereby represents that he or she is duly authorized and has the power to execute this Agreement on behalf of himself or herself, and in the case of a minor child or a person for whom he/she claims to have been appointed the guardian of, the patient.

2)  This Agreement shall be governed by the laws of the State of Virginia.

3)  This Agreement shall not be modified in any way except in writing executed by all of the parties hereto.

4) If any provision or provisions contained herein shall contravene or be invalid under applicable law, such contravention or invalidity shall not invalidate the full Agreement, but the Agreement shall be construed as not containing the particular provision or provisions held to be invalid and the rights and obligations of the parties shall be construed and enforced accordingly.

5) This Agreement shall be binding upon and shall inure to the benefit of the parties and their respective legal successors, representatives, heirs, spouses, administrators, and any person or entity claiming by, through, or under any one or all of the parties.

6) No waiver of any provision of this Agreement shall be binding unless executed in writing by the party to be bound thereby. No single waiver of any provision will constitute a further waiver of that provision or a waiver of any other provision.

7) In any future dispute regarding, or in any way relating to the terms of this Agreement or its enforcement, the prevailing party shall be entitled to his costs including attorney’s fees and expert fees including those by a collection agency. 

8) Any fees that remain unpaid and due shall bear interest at the rate of 20 percent (20%) per annum from the date the services were in fact rendered.

Cancellation Policy

If the patient does not appear on time or fails to keep the scheduled appointment time as agreed, the non­ refundable charge of $400.00 is forfeited by the patient. If the procedure is canceled due to the patient not following the fasting, eating or drinking restrictions, the non­refundable charge of $400.00 will be forfeited by the patient. 

Rescheduling due to unexpected illness or family emergency may require a physician/pediatrician clearance. The $400.00 fee will be credited (but not refunded) toward a future available appointment.