Oral Surgery Financial Policy and Payment Agreement

Patient Information

Name: _________________________
Date of Birth: __________________
Account #: ______________________

Financial Policy

1. Payment Responsibility

• Full payment is required at the time of service unless prior arrangements have been made
• We accept cash, personal checks, and major credit cards (Visa, MasterCard, American Express)
• For extensive procedures, payment plans may be arranged through our office or third-party financing

2. Insurance

• As a courtesy, we will file insurance claims on your behalf
• You are responsible for providing current insurance information
• Your insurance policy is a contract between you and your insurance company
• You are responsible for any balance not covered by insurance

3. Deposits and Scheduling

• A deposit of 25% is required to schedule surgical procedures
• Deposits are non-refundable if cancellation occurs less than 48 hours before the appointment

4. Fees and Charges

• Returned check fee: $35
• Late payment fee (after 30 days): 1.5% monthly
• Missed appointment fee: $50

5. Collection Policy

• Accounts over 90 days past due may be referred to a collection agency
• All collection costs will be added to the outstanding balance

Agreement

I have read and understand the financial policy above. I agree to be responsible for all charges not covered by insurance.

Signature: _________________________ Date: _____________

Print Name: ________________________

Office Use Only

Received by: _______________________ Date: _____________