Www.parksoms.com



Financial PolicyPatient’s Name:___________________________________Date of Birth:_________________________InsuranceYou must present photo ID and insurance cards at first appointment. As a courtesy we will file your claim for you. It is your responsibility to know your coverage, benefits and network participation. We will verify benefits on receipt of insurance cards and policy holder’s information. Your co-insurance and any unmet deductible is due at the time of service. Any balance after insurance pays is your responsibility. MedicareMedicare does not cover dental extractions, bone work or other dental related services therefore it is your responsibility for these charges. Dr. Parks has opted out of Medicare and does not bill Medicare/Medicare Advantage Plans for any medical/dental services that may be covered. You will be asked to sign an opt out form for any medical/dental services that may be covered by a Medicare provider. MedicaidOur office does not bill medical Medicaid for dental extractions. Dr. Parks does not participate with any Medicaid dental or medical plans. Method of PaymentOur office accepts cash, check, Care Credit and all major credit cards. We do not accept postdated checks. Returned check fee is $25.00.Care CreditOur office participates with the 6 month interest free plan with Care Credit. The card holder and card must be present. All refunds will be credited back to the Care Credit account. Assignment of BenefitsI authorize the holder of medical or other information to release my insurance carrier, governmental agency or its intermediary, any information needed for this or a related insurance claim. I agree to pay any charges incurred by me to this office. I have read and understand this financial policy. Patient’s Signature:________________________Relationship to Patient:______________Date___________________ Patient, Parent, Guardian or Legal Representative ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download