Financial and General Policies
We are pleased that you have chosen the Midland Oral & Maxillofacial Surgery P.A. for the evaluation and management of your surgical needs. We hope that your experience here will be exceptional. We strive to communicate clearly and effectively with you in all aspects of your care. We have created this policy so that you understand our expectations regarding insurance and payment for services. If you have any questions, please address those to the receptionist or office manager before you sign the acknowledgement.
1. Forms of payment: Payment for services is expected prior to procedures that are performed. For
your convenience, we accept cash, checks and money orders as well as Visa, Master card and American Express. You will be responsible for paying a $30.00 fee for returned checks.
2. Insurance Benefits: Your referring Dentist may be willing to file your insurance claims as an added service to you. However it is important that you understand that Dr. Austin D. Gray DDS is a specialist and out-of-network. Additionally, it is important that you understand that your insurance company does not share financial responsibility for your bill. You are responsible for all charges if your insurance company fails to pay.
3. Patient Portion vs. Insurance Portion: Every effort will be made to declare your estimated cost prior to commencing with your procedure, but sometimes may require modification due to unforeseen circumstances. We will notify you of that portion either orally or written and you will be expected to pay your estimated portion on or before the service date. As mentioned above, the insurance portion is estimated and is never a guarantee of payment even after an authorization has been obtained
5. Denied or Unpaid Insurance Claims: Your referring dentist will work with your insurance company to receive reimbursement for your services. However, if an insurance company does not remit payment
within 120 days of the service date, you will be responsible for the balance. For this reason, we encourage you to communicate with your insurance company about your outstanding claims. Additionally, if the insurance company denies payment on service, and our attempts to appeal the denial fail, you are responsible for the balance. Unfortunately, this sometimes happens even after the service has been pre-authorized.
6. Financial Arrangements: In the event of financial hardship, optional payment arrangements may be
discussed with the office staff before the planned date of the procedure or surgery. Since the doctor's
main focus is on your health and treatment, they are unable to discuss fees or payment arrangements with you. If alternate arrangements are not requested and agreed upon before the date of the procedure. full payment of the patient's estimated portion will be due, as detailed in this policy.
7. Surgical Deposits: In an effort to provide surgery as quickly as possible following your consultation we require a $200.00 deposit to make a surgical appointment. We find that this minimizes wasted clinical time that could have been allocated to other patients and keeps our booked surgeries from stretching many weeks into the future. This deposit is simply intended to be applied to the surgical bill on the date of surgery. However it will be forfeited to Midland Oral & Maxillofacial Surgery P.A. in the event of a no show on day of surgery. Additionally, It will be forfeited for declining or cancelation of a scheduled surgery inside the 7 days immediately preceding the appointment. It will not be forfeited in the event of a rescheduling of appointment.
8. Late arrivals: We strive to keep wait times to a minimum and expect that you arrive 15 minutes before your scheduled appointment. In the event that you arrive 15 minutes or later to you appointment we reserve the right to cancel/reschedule your appointment. This is considered a failed appointment.
9. Cancellation of Appointments: In fairness to other patients and the doctor, we require 24 hours
notice if you must cancel an appointment. We reserve the right to charge a $25 fee for missed
appointments without 24 hour notification. This likewise is considered a failed appointment.
10. Failed appointments: Two failed appointments may result in no future appointments being given.
11. Doctor patient relationship: In the event of poor compliance by patient, or a breakdown in patient doctor relationship it may be in patient’s best interest and Midland Oral & Maxillofacial Surgery PA’s interest that this doctor patient relationship be terminated. Consequently we reserve the right to terminate doctor patient relationship at any time during you treatment at Midland Oral & Maxillofacial Surgery P.A. if deemed appropriate. Recommendations for other practitioners will be made and emergency care provided for no less than 30 days will be rendered. Notice of termination of Doctor-Patient Relationship will made verbally and delivered in written form.
12.Your Patient Records: In the event that you desire a copy of your treatment records from Midland Oral & Maxillofacial Surgery P.A. a written request must be made. Additionally a nominal fee of $30.00 will be required to cover expenses for reproducing record. Radiographs can only be delivered in digital form. Your medical record must be received in person. Requests will require one business day to process.
Thank you again for entrusting us with your care. If you have any questions about this policy or
something not addressed in the policy, do not hesitate to ask a member of our office staff.