Are you taking any of the following?

Are you taking, or have you ever taken bone density medications, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast,
or Evista in the past 12 years?

Are you allergic to, or had a reaction to any of the following:

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member his/her staff, responsible for any errors or omissions that I have made in the completion of this form.

Please read the following Financial & Insurance Policy in regards to treatment rendered by Craig E. Vigliante, M.D., D.M.D., Michael T. Gocke, D.D.S., Alexander Sonesson, D.M.D., at Reston Advanced Oral & Cosmetic Facial Surgery.

Our Courtesy Service to You Includes:

1. Verifying your dental insurance to advise you of estimated benefits available to you. PLEASE NOTE: Verification of benefits does not guarantee payment by your insurance company. Therefore, you should also verify and understand your insurance benefits.
2. Filing your dental insurance with your dental insurance carrier.

Our Expectations of You the Patient or Guarantor:

1. Co-payments for treatment rendered are due the day the service is delivered.
2. Professional service fees are charged to the patient, NOT YOUR INSURANCE COMPANY. Your insurance company has no obligation to pay for our services; your insurance company’s obligation is to you, the policy holder. You are responsible for payment of your account within the time limits of our financial policy. We will try to assist you with any problems concerning your insurance.
3. Insurance claims not paid by your dental insurance company within sixty (60) days from the date of our filing will then roll over to the Responsible Party on the account.

Cancellation & No-Show Policy:

Our goal is to provide quality individualized care in a timely manner. Late cancellations and No-Shows (includes arriving more than 15 minutes late) create inconvenience and prevent scheduling of other patients who need access to medical care in a timely manner. Patients who do not show up for their surgical appointment or provide less than 48 hours in advance cancellation notice will be subject to a $500.00 NO SHOW fee. This fee will not be submitted to insurance. It is your responsibility and must be paid in full.

Please Note:

1. We will do our best to estimate what your insurance will pay for services. However, this is an estimate. Some plans base an amount of benefit on a schedule of fees arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage of the reimbursement indicated in your dental plan. For example, if your plan states that it will pay 80% of the usual and customary cost per procedure, it means 80% of the fee determined by the insurance company, and not the actual fee charge by our practice. The patient is ultimately responsible for what the insurance does not cover, if applicable. If you have any questions, please feel free to ask one of our office administrators.
2. We will require a minimum of $250 non-refundable deposit in order to secure appointments for any services that are over one hour of surgical time.
3. All accounts over ninety (90) days will be considered past due.
4. Past due accounts are subject to eighteen percent APR (18%) of 1.5 monthly finance charges.
5. Past due accounts may be referred to our collection agency for collection. In the event of default on our account, you will be responsible for thirty-three and one-third percent (33-1/3 %) attorney collection fee as well as any and all collection agency charges.
6. This office will accept the following instruments of payment for services rendered: Visa, MasterCard, Discover, Cash, Certified Check, Personal Checks ($500.00 or less).
7. Personal checks that are returned due to “insufficient funds” are subject to a $50.00 service fee.

I have read and understand the Financial Policy and Insurance Policy for Reston Advanced Oral & Cosmetic Facial Surgery. I agree to be responsible for payment and all terms for services rendered on my behalf or that of my dependents.

As a patient, please be advised that in accordance with Section 32.1-45.1 of the Code of Virginia, 1950, as amended, that if the provision of health care services to the patient exposes any person employed by or under the direction and control of this facility or any other healthcare provider, to the patient's body fluids in a manner which may transmit immunodeficiency virus or HIV or Hepatitis B or C viruses, then the patient will be deemed to have consented to testing for infection with HIV or Hepatitis B or C viruses, and the release of such test results to the person(s) exposed.

I hereby acknowledge that a copy of the patient Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

The release of information will remain in effect until terminated by me in writing.

We are happy to learn of you obtaining dental, oral and maxillofacial professional services from Reston Advanced Oral & Cosmetic Facial Surgery. However, please note that our Practice is not a participating provider in the Health Net/Tricare/Champus program. In an effort to address billing limitations which may apply to Health Net/Tricare/Champus non-participating providers, we have found it necessary to identify Health Net/Tricare/Champus program beneficiaries upon their initial contact with our Practice, to inform them of our Practice Policy, prior to being treated as a patient.

Please indicate below if you are currently receiving benefits under any Health Net/Tricare, Champus healthcare program. If you are, please check the “YES” box within Part A, and complete Part B. Please note that our willingness to provide healthcare services to you is expressly conditioned upon the fact that you are either (1) not a Health Net/Tricare/Champus, or (2) to submit a letter and any other documentation reasonably required by Health Net/Tricare/Champus to waive the balance billing limitation on all services that we may provide to you.

PART A – Please check one of the following:

PART B – Only complete this section if you marked “YES” within Part A.

I am currently covered by the following Health Net/Tricare/Champus healthcare programs, and have provided a copy of my beneficiary cards to the Practice indicating my status under such programs.

I hereby acknowledge that to the best of my information, knowledge and belief that the information I have provided in Part A and Part B (if applicable) of this form is true and accurate, and herby agree to promptly notify the Practice concerning any change in such information prior to receiving professional services from this Practice.

I understand and agree that my initials below and my signature on this form indicate my agreement to submit a letter and/or other reasonable documentation required by the relevant Health Net/Tricare/Champus healthcare contractor(s), with a copy to the Practice, indicating my desire for Health Net/Tricare/Champus to waive the balance billing limitations which may be imposed upon the Practice for procedures which may be performed on me by the Practice. The Practice agrees to provide me with a letter which I may consider utilizing for this submission. I agree to promptly provide the Practice a copy of any written correspondence I may receive from Health Net/Tricare/Champus healthcare concerning my request(s) for the aforementioned waiver.

I acknowledge and agree that this requirement shall be an express condition to the Practice’s willingness to accept me as a patient, and that my failure to either meet these conditions or failure of the Health Net/Tricare/Champus healthcare contractor to accept my written for a waiver may result in the Practice’s unwillingness to treat me. I understand that the Practice may pursue any other remedies available to it under applicable law based upon errors or omissions in this form, or any failure to meet the above conditions. Finally, I agree that such actions by the Practice shall not result in my abandonment as a patient, and that the Practice may waive these requirements for certain Health Net/Tricare/Champus healthcare programs, in the Practice’s sole discretion.

We are happy to learn of you obtaining dental, oral and maxillofacial professional services from Reston Advanced Oral & Cosmetic Facial Surgery. However, please note our Practice has Opt-Out of Medicare; therefore, we will not be able to file a claim for you and/or you cannot file a claim to Medicare for reimbursement. In an effort to address billing limitations which may apply to Medicare, we have found it necessary to identify our Medicare beneficiaries upon their initial contact with our Practice, to inform them of our Practice’s Medicare Opt-Out Policy, prior to being treated as a patient. Please note that our willingness to provide healthcare services to you is expressly conditioned upon the fact that you are fully aware that we are Opt-Out of Medicare and a claim will not be generated, and you will not be reimbursed by Medicare.

• I acknowledge that Medigap plans do not, and that other supplemental insurance plans (such as FEP) may elect not to, make payments for services furnished by a physician or practitioner under the “opt-out” contract.
• I agree to be responsible for payment.
• I acknowledge that the physician or practitioner is not limited to the amount that he or she may charge for services rendered.

I authorize my surgeon and his/her staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers.