Fresno Oral Surgery Group   

Doctors Karian, Wiggins, Alexander & Julian

We would like to welcome you to our office. We are here to serve you with every resource at our command. Your health care is important to us. It is is our desire that every patient receive prompt, timely and courteous service when visiting our office. Therefore, to prevent any misunderstanding we would like to point out:

INSURANCE AND PAYMENT FOR YOUR ORAL SURGERY CARE

Your insurance coverage is a contract between you and your insurance company. It is not possible for us to pro­vide service on the basis that the insurer will always pay all charges, as coverage varies so greatly.

OUR POLICY IS AS FOLLOWS:

1.   Although we submit insurance claims for you, payment, in full, is due at the time services are rendered.

2.   As a courtesy to our patients, we submit one insurance claim free of charge. For each additional insur­ance claim the charge is $7.00 per claim, paid in advance. There are some insurance companies that require X-rays to be sent with the insurance claim form. If your insurance company is one of those, your X-ray must be duplicated for that purpose. The charge to our office for duplication is $5.00. You will be billed for that amount.

3.   Any payment received from an insurance company, on a paid account, is promptly reimbursed.

METHODS OF PAYMENT

To provide you with the most convenient method of payment, we will gladly accept your MasterCard, VISA or Personal Check.  There will be a $50.00 charge for returned checks

FEES CHARGED BY OUR OFFICE

Our fees are based on the published and widely used relative value schedule for oral surgery.  We will be happy to answer any questions you may have regarding these fees.

INTEREST CHARGES

There will be an interest charge assessed of 1 percent per month for any account balance not paid in full within 30 days following your first visit. Thereafter, it will be calculated on any balance remaining or charged to your account. This periodic interest charge is equivalent to an annual percentage rate of 12 percent.

MY PAYMENT PREFERENCE TODAY IS: CASH [ ]  CHECK [ ]  VISA [ ] MASTERCARD [ ]  DISCOVER [ ]AMERICAN EXPRESS [ ]

____________________________________________                                                                                        _________________

Signed                              (financially responsible party)                                                                                         Date

Services we provide, including surgeries, are classified as DENTAL. If you have DENTAL COVERAGE please provide the following information:

Primary insurance company name:   Group #

Address to mail claim:     City___________________ ST                          ZIP_________

Name of insured person     Date of Birth Social Security # _____-                      -_____Relationship of Patient to Insured:Self [ ] Spouse [ ] Dependent [ ] Other [ ]

Second insurance company name:            Group #

Address to mail claim: City ST        ZIP_________

Name of insured person       Date of Birth

Social Security # _____-                      -_____Relationship of Patient to Insured:Self [ ] Spouse [ ] Dependent [ ] Other [ ]

I authorize the release of any information pertaining to this claim. I understand that I am financially responsible for all costs of treatment. I authorize payment of benefits directly to the doctor. In the event that my insurance contract calls for direct payment of benefits to me, I authorize and request that the check be mailed to me as follows: do Drs. karian, Wiggins, Alexander and Julian, 3812 N. First Street, Fresno, CA 93726

___________________________________                                                    __________________________________

Patient Signature (parent if patient is a minor)                                                   Insured Signature                       Date