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Additional Patient Information

 

First Visit

Scheduling

Financial Policy

Insurance

Office Hours

How to Find Us

Forms

 
 
 
 
 

In an effort to avoid misunderstandings and to keep the high cost of billing to a minimum, thereby being able to maintain fees at a reasonable level, we are presenting you with a statement of the office policies concerning payment of your account and the processing of your insurance.

This office is happy to cooperate with the patients who are covered by insurance.

INSURANCE COVERAGE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY.

We ask that you read your policy to be sure that you are aware of any limitations of the benefits provided.  It is important to understand that in most cases your insurance is designed to reduce your cost, NOT eliminate it completely.  You are ultimately responsible for the full amount of your bill, regardless of your insurance coverage.  The office will provide you with an ESTIMATED COST of services to be rendered.  It is not the responsibility of the office to verify insurance coverage, rules, maximum or participation.

Payment is expected at the time of treatment.  The office accepts use of MasterCard and Visa.  In the event my account becomes delinquent and becomes assigned to a collection agency, I agree to pay all collection agency fees, court costs and attorney fees.  I understand that all accounts with a balance over 30 (thirty) days will be assessed a 1.5 percent late charge per month on the unpaid monthly balance or $25 per month (at the office's discretion).  Any checks returned to the office are subject to an additional fee of $35.00.  Immediate remittance in the form of cash. money order or certified funds is expected.

Occasionally, during a surgical procedure, situations are encountered that require additional services, which could not be anticipated beforehand.  Fees for these additional services will be charges at the time of treatment.

We are now able to offer 6 month interest free financing is available on any work over $500 through Care credit.  Please ask the receptionist for more details.

MINOR PATIENTS: Patients under the age of 18 MUST BE ACCOMPANIED BY A PARENT OR LEGAL GUARDIAN.  All fees involved must be paid by the guardian present at the time of service.  This office will not bill another party or guardian for the minor patient.

Please be advised that our office will be as flexible as possible to meet your needs in scheduling appointments.  Kindly give 48 hours’ notice prior to canceling an appointment in order to avoid a charge of $30 per 30 minutes of appointment time.

 

Print and Complete this form before your first visit to our office

     
     

 

   
 

6 Park Center Court, Suite 204
Owings Mills, MD 21117
Phone: 410-356-7726     Fax: 410-356-6933

2014 Tollgate Road, Suite 108
Bel Air, MD  21015
Phone: 410-569-2243     Fax: 410-356-6933