For your convenience, we accept Visa, MasterCard, Discover and American Express. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered. If you have questions regarding your account, please contact us at Mountain View Oral & Maxillofacial Surgery Phone Number 303-694-1700. Many times, a simple telephone call will clear any misunderstandings.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated.
Mark D Berman, D.D.S., M.D., P.C.
We believe our financial policies represent sound business practice, which allows us to provide high quality, cost effective care to our patients. We do not want financial problems to be a barrier to your treatment, as quality care to you is our primary concern. However, please understand that payment of your account is an important aspect of the service you receive here. The following is a statement of our Financial Policy, which we require that you read and sign prior to your treatment.
Charges for medical/dental services in our office are due and payable at the time the services are rendered. If you have insurance you must understand that it is an agreement between you and an insurance company to pay you a certain amount to cover medical/dental care. As a courtesy to our patient we will file your claim to your insurance company. Your doctor’s bill is an agreement between you and your doctor. You are responsible for the payment of your bill in full regardless of the status of your insurance claim.
IN-NETWORK INSURANCE PLANS
An estimated co-insurance (typically 20%) — OR — a co-payment determined by your contract with your insurance company is expected at time of service. We are under a contractual obligation to your insurance company to collect all deductibles, co-payments and co-insurance amounts. We reserve the right to notify your insurance company of any non-compliance of your financial obligation and to assess interest charges and/or re-bill fees on unpaid patient balances.
INDEMNITY and NON-CONTRACTED INSURANCE
With appropriate insurance information, we will bill your insurance as a courtesy to you. Please note that your insurance policy is a contract between you and your insurance company. We are NOT a party to that contract. You should direct any questions or concerns regarding your coverage to your insurance carrier. Any bills incurred are automatically your responsibility.
PATIENTS WITH NO INSURANCE OR IF YOU HAVE CHOSEN TO BILL YOUR OWN INSURANCE
Payment is due IN FULL at time of service, unless prior arrangements are made.
- For your convenience, we accept checks, cash, Visa, MasterCard, and Discover.
- A $25 returned check fee will be issued for all checks returned from your financial institution.
- A 1.5% finance charge may be added to any unpaid balance over 30 days.
- An additional fee will be added to every account that is sent to collections.
The patient is responsible for any applicable attorney’s fees for the collection of debt.
Helping You Understand Your Dental Insurance.
It is your responsibility to know your dental benefits and coverage limitations. There are many ways in which dental plans are designed and how reimbursement levels are determined. You need to know how your dental plan is designed and its limitations. Your dental plan is designed to share in your dental care costs. It may not cover the total cost of your bill. Many plans cover between 50 to 80 percent of dental services.
We will try to help explain dental plan issues to you. However, we may not be able to answer specific questions about your dental plan, or predict what your level of coverage for a procedure will be. This is because plans offered by the same employer or written by the same third-party payer can vary significantly according to the contracts involved. If you have questions regarding your dental plan, or a problem with a reimbursement level, contact your employer or insurance company.
- Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients. You are responsible for any unpaid balance regardless of your insurance company’s arbitrary determination of usual and customary rates.
- Preferred Providers
Your plan may want you to choose your care from a list of their preferred providers. Whether or not you choose your dental care from this defined group can affect your levels of reimbursement.
- Annual Maximums
Your plan purchaser makes the final decision on “maximum levels” of reimbursement through the contract with the insurance company. This is the maximum dollar amount a program will pay toward the cost of dental care incurred by an individual or family in a specific time period (also known as: maximum allowable charge). Many plans today have an annual maximum of $1,000 or $1,500. We are unable to tell how much you have toward your maximum at the time of your treatment here.
- Treatment Exclusions
Your plan may not cover certain procedures, such as IV sedation or dental implants. This does not mean these treatments are unnecessary. Your dentist can help you decide what type of treatment is best for you.
- A Predetermination of Benefits Does Not Guarantee Coverage
We may be able to determine if a procedure is a covered benefit of your plan. However, this does not guarantee that a benefit will be paid. Once an annual maximum has been met a predetermination of coverage done prior does not guarantee coverage.
Any account balance(s) that are not paid by 90 days from the time of service may be forwarded to a collection agency. If deemed necessary, Mountain View Oral and Maxillofacial Surgery reserves the right to forward the account balance(s) to a collection agency prior to 90days from the date of service. Any and all phone numbers provided to our office, be it residential, employment or wireless, are authorized methods of communication by our office or by a collection agency in regards to any outstanding collection balances. Should collections be necessary, any payment made to the collection agency via an electronic payment (such as a check over the phone or a credit card) will incur a convenience fee. A convenience fee is a fee incidental to your payment obligation. Should litigation be necessary to collect an amount owed, the responsible party agrees to pay all cost of collection including, but not limited to, collection fees, attorney fees, interest at the rate of 18% and court cost.
We will be happy to address any questions or concerns you may have after reading our Financial Policy.
I have read and understand the Mountain View Oral Surgery Financial Policy and acknowledge a copy of this policy has been given to me.
Signature ____________________________________________ Date__________________