Patient Information

Financial Information

OUR FINANCIAL AGREEMENT

WELCOME
Thank you for choosing us for your Oral Surgery care. We are committed to providing excellent care, and payment of your bill is part of successful treatment. Our financial policy is based on an open and honest discussion of fees. You may ask our staff for an estimate prior to seeing Dr.Doucet.

ARRANGEMENTS FOR PAYMENT IN FULL ARE DUE AT THE TIME OF SERVICE.
We accept Cash, Checks, Debit ATM Cards, Visa, Mastercard, Discover, and American Express. We also offer financing through Care Credit which has interest free financing for 3 to 12 months. More extensive financing is offered at low fixed rates.

USUAL AND CUSTOMARY RATES
We are committed to providing excellent oral surgery treatment to all our patients. Our fees reflect our commitment to the quality our patients deserve and are considered usual and customary for the area, regardless of any insurance company's determination.

OUTSIDE LABORATORY FEES
If pathological services are performed in our office, the use of an outside laboratory will be necessary. The pathological review and report will be billed to you separately from the laboratory. It is your responsibility to inform us if your insurance carrier/plan utilizes a specific outside laboratory. The average fee for oral specimens' pathological review by an outside laboratory is
$100.00 - $200.00

INSURANCE
As a service to our patients, we will bill your insurance company if you bring in all necessary insurance information, both dental and medical. Your insurance policy is a contract between you and your insurance company. As a health care provider, we are not party to that agreement. In the event we accept assignment of your insurance benefits, we require that pre-approved arrangements be made on the entire amount. Insurance policies vary and services provided may not be covered. Our office is committed to helping our patients maximize their benefits; we require that pre-approved arrangements be made on the entire amount.

MINORS
Payment for services of the treatment of minors is the responsibility of the adult accompanying that minor.

MISSED APPOINTMENTS
Be advised that the policy of this office is to charge for missed appointments unless the appointment is canceled 24 hours in advance for consultation appointments and 48 hours for surgical appointments. Cancellation 48 hours or less prior to a scheduled surgery appointment date are subject to a cancellation fee up to $500 regardless of actual damages or reasons for cancellation. Cancellation 24 hours or less prior to all other types of appointment other then post-operative are subject to a cancellation fee of $100 regardless of actual damages and reasons for cancellation. We may require a deposit to reserve a place in our surgery schedule.

SERVICE CHARGES
The policy of this office is to charge a $20.00 rebilling fee on all accounts that are over 30 days past due. We will charge $25.00 for returned checks.

COLLECTION FEES
Fees incurred to collect payment will be billed to, and are payable by the patient/responsible party.

FINANCIAL CONSENT
The patient (or Guardian) agreed to be fully responsible for the total payments of treatment performed in this office.

RELEASE OF INFORMATION AND CONFIDENTIALLY DISCLOSUSRE
• This signature on file is my authorization for release of information necessary to process my claim. I hereby authorize payment to Dr. Doucet of the benefits otherwise payable to me.
• I give my permission for the clinical information in this chart to be reviewed by another qualified doctor for the purpose of quality assurance.
• For the purpose of verifying your appointment date and time, presenting specific instructions, and updating your account information, we may need to leave a message with you, an individual in your residence, or your voice message system unless otherwise instructed by you to not do so.

I UNDERSTAND AND AGREE TO THE FINANCIAL POLICY AND
CONFIDENTIALITY AGREEMENT