Thank you for choosing Oral Surgeons as your specialty provider. We are proud to have the privilege of providing you care. The following is a statement of our financial policy that we require you to sign prior to treatment.

Delta Dental is the only insurance company with whom we participate. Payment is required at the time of treatment, unless special arrangements have been made. Dental and/or medical insurance is a contract between you, the patient, and your carrier. Certain procedures may not be covered expenses by your plan. We recommend that you contact your insurance prior to treatment and review your entitled benefits. Our doctors and business office staff are happy to assist you by providing pre-estimates and insurance coded walk-out statements when necessary. Often we are asked by your insurance carrier to provide copies of the pre-exam, treatment plan, x-rays, and before and after treatment notes. Therefore, this would also be used for consent to release information to your insurance company.

We are dedicated to the delivery of high quality care for our patients. Our fees represent a very fair value to our patients based upon the cost of business in our local area. We do not adjust our fees to the insurance industries arbitrary assessment of value for a given procedure.

The doctor frequently provides an estimated fee for services on larger procedures. This is only an estimate and may change after treatment according to services provided or periodic fee increases.

An adult guardian must accompany any patient under the age 18 for consultation and treatment. When this is not possible, prior arrangements for consent to treat and for payment must be made.

Please help us serve our patients better by keeping scheduled appointments. A fee may be charged to patients who miss appointments without 24 hours prior notice.

This office does not participate with the Medicare System. All services provided will not be covered under Medicare Part B (outpatient services). No claims to Medicare Part B may be submitted for your services by OSA or yourself. The patient understands full responsibility for payment to our office.

Thank you for understanding our financial policy. Please inform our staff if you have any questions or concerns.

I UNDERSTAND AND AGREE TO THIS FINANCIAL AND CONSENT POLICY