Thank you for choosing Oregon Dental Anesthesia as your anesthesia care provider. We are committed to providing you with the best possible care. Your clear understanding of and agreement to our practice financial policy is important to our relationship. The following is a statement of our Financial Policy. We require you to read and sign this document prior to any treatment.
REGARDING DURATION OF ANESTHESIA
Fees will vary depending on the duration of the dental treatment. Your dentist will provide an estimate of the time needed for the procedure(s). While we work with your dentist to make every effort to present accurate fee estimates before each procedure, unforeseen situations occasionally arise during the course of treatment that necessitate a change in the treatment plan or in the fee for a particular procedure and the accompanying anesthesia.
REQUIRED UPON CHECK-IN
1. Verification of personal contact information via current picture ID, when applicable.
2. Payment of the fee for the estimated duration of anesthesia. If the duration of time increases due to a change in the treatment plan the additional balance will be payable upon check-out.
3. Verification of medical health history.
4. Verification that pre-anesthesia fasting instructions have been followed.
Payment for the anesthesia services is due on the day of treatment. For your convenience we accept cash, Visa/Mastercard, Discover, American Express, and Care Credit. Sorry, but we cannot accept personal checks.
FOR PATIENTS WITH INSURANCE
We will always supply a superbill following the appointment. This superbill (also known as a claim form) will have all the appropriate dental and medical insurance anesthesia codes and the doctor’s portion filled out. This superbill can be sent directly to the insurance company to obtain maximum allowable reimbursement under your policy. We are not responsible for billing your insurance for our services nor are responsible for any payment/non-payment by your insurance.
It is important that reimbursement for the anesthesia fee by dental or medical insurance programs NOT be assumed. Many policies do not pay for anesthesia services for dentistry.
Oregon Dental Anesthesia is not party to your divorce decree. The responsibility for minors rests with the accompanying adult.
ACKNOWLEDGEMENT AND AGREEMENT
By signing below, you the patient (or guarantor, if the patient is under 18) agree to the above terms and have had opportunity to ask questions and have had those questions answered to your satisfaction.