Thank you for choosing SAI Oral Surgery. We are committed to providing the highest quality care at a reasonable cost. In this era of rising healthcare expenses, we will make every effort to keep costs down. However, we will not sacrifice quality and patient care to reduce costs. To avoid misunderstandings, we ask you to read and sign our financial policy prior to treatment.

• You are responsible for your charges: Patient or their legal guardian are responsible for all charges incurred during treatment and must pay for services. We will file your insurance claim as a convenience to our patients, but our relationship is with you and not your insurance company. You remain legally responsible for your bill.

• Payment for service: Payment is required at the time that the service is provided. Early morning appointments, prior to 8:00am, must be paid the day prior to appointment. Payments may be made by Cash, Personal Check, Visa, MasterCard, and American Express. Financing is available through CareCredit.

• If you do not have insurance, or if you require an emergency, same-day, appointment: Payment in full is expected at time of service. Same-day surgeries are up to the discretion of the surgeon and cannot be guaranteed.

• If you have insurance: As a valued service to you, we will investigate your insurance benefits, estimate your out-of-pocket costs and file claims on your behalf.

o You must pay for estimated out-of-pocket expenses, such as estimated co-payments, deductibles, non-covered services requiring further review by your insurance carrier before treatment is initiated. Any charges remaining after insurance will be charged to the credit card place on file with our office.

o An insurance estimate or verification of benefits is not a guarantee that your insurance company will pay exactly as estimated. Your insurance company determines the final amount paid at the time the claim is processed.

o Payment in full is expected no longer than 90 days after your claim has been filed by us. Insurance payments are required to be made by insurance companies within 90 days of filing. However, if your insurance company has not paid within 90 days, you will need to contact your insurance company to investigate claim status. If your payment is not received within 90 days of filing or if your claim is denied, you will need to pay the balance in full at that time.

o We will cooperate with your insurance company to assist with processing your claim. Please do not submit additional claims or information to the insurance company unless specifically requested.

o Your insurance policy is a contract between you and your insurance company. The doctors are not part of the contract. Therefore, all charges incurred are your responsibility. You are responsible for payment whether or not your insurance company pays.

• Patients with Medicare: We do not accept Medicare.

• Patient with Medicaid (public aid programs): We are not Medicaid providers. Payment in full is required for services.

• Minor patients: The parent or guardian accompanying a minor is responsible for payment of services. Regardless of insurance coverage, patients age 18 and older are responsible for payment unless a parent accompanies them to the initial appointment and signs this agreement.

• Divorce situations: The parent who brings the child to the initial appointment is responsible for all charges incurred during treatment, regardless of who provides insurance coverage. Our office will not become involved in payment disputes between divorced parents.

• Returned checks: A $25 service fee will be charged for returned checks. Temporary or post-dated checks are not accepted.

Collection fees: If it becomes necessary for our office to use a collection service and/or legal assistance, a $50 collection fee will be added to your account.

I have read, understood and agree to the above financial policies regarding payment for professional services. I understand I am fully responsible for, and agree to prompt payment of, the full amount of fees and expenses regarding my account. I realize my insurance may deny services or not pay as anticipated.

I further consent to be contacted by the practice or any agent of the practice, or any collection agency or attorney to whom an unpaid account balance has been assigned, at any address or phone number provided (whether cell phone or landline) provided to the practice or their agents, including mail, electronic mail, phone or text message.

I authorize my insurance benefits be paid directly to SAI Oral Surgery.