Financial Information

5% Savings:
To assist our patients with their treatment cost, a 5% reduction of treatment plan fees applies when payment
in full is received at the time of service (this discount is not available to patients with 100% insurance
coverage, with insurance plans that offer greater ppo discounts, or with accounts using CareCredit). Our
office accepts cash, check, Visa, Master Card, Discover, American Express, and CareCredit.

Insured Patients:
Insurance plans are a contract between the patient and the insurance company. Insurance coverage varies
widely, and benefits cannot be guaranteed. Patients should contact their individual insurance companies if
there are questions on plan benefits and coverage. For patients that have both medical and dental insurance,
a 20% down payment of the estimate total will be required at the time of surgery. In addition, a Final
Payment Arrangement form (secure credit card authorization for payment on balances after insurance) will
need to be completed to avoid monthly service charges on balances not paid in full. Insurance claims are
filed if complete insurance information is provided to our office. Any remaining balance after insurance has
processed is the patient’s responsibility. If there is a credit or overpayment on the account, a refund will be

Non-Covered Benefits:
For accounts with no insurance, medical insurance only, dental implant procedures and/or appliances, full
payment is required at the time of service. This makes patients eligible for a 5% discount. If there is a credit
or overpayment on the account, a refund will be issued.

Treatment Plans over $6,000
Many insurance plans have annual maximums and limitations on coverage for large procedures. For any
treatment totaling more than $6,000, we require payment in full prior to surgery. Our office will require a
50% deposit at least one week prior to your reserved appointment, and the remaining balance will be due on
the day of surgery. Patients are still eligible for the 5% discount, with exceptions stated above. After
insurance processing, if there is a credit or overpayment on the account, a refund will be issued.

No Surprise Billing
All patients are provided with an estimated treatment plan after their initial evaluation. This estimate will
include insurance procedure codes, the description of procedures, and our standard fees (prior to any
insurance contributions). Treatment plans will indicate if the insurance company given at time of evaluation
is contracted as an in-network provider with Oral & Maxillofacial Surgery Fox Cities. In-network provider
adjustments can only be taken if Oral & Maxillofacial Surgery Fox Cities, S.C. has signed a direct
agreement/contract with that insurance organization. If the patient’s insurance is not listed as an in-network
provider, the patient is consenting to be treated by an out-of-network provider which is allowed to
send a balance bill (the difference between what insurance paid and what the doctor charged) for any
remaining payments. Patients may then be financially liable for significantly more than if they had insisted
on care by an in-network provider.

Workers’ Compensation:
If the services received are due to an accident or injury at work, please inform our business staff. Our office
will assist with filing claims if complete information is provided. The collection of fees through Worker’s
Compensation, personal injury, auto accidents, or other litigation is the patient’s responsibility.