Colorado Center for Oral & Facial Surgery, P

Stein Oral & Facial Surgery, P.C.

FINANCIAL AGREEMENT

I the undersigned, in consideration for services rendered to the patient by

Dr.StephenM.Stein, DDS, understands and agrees to the following:

Payment for charges is due at the time of service. We accept Visa, MasterCard, Discover, Cash, Debt Card, or Certified funds.

For insurance companies we agree to bill on your behalf, we will collect between 20% and 100% of the estimated fees the day services are rendered. Credits and overpayments are refunded to the patient.WE ARE OUT OF NETWORK ON ALL INSURANCE COMPANIES. OUT OF NETWORK BENEFITS AND DEDUCTABLES APPLY. WE ARE A FEE FOR SERVICE PRACTICE AND BILL INSURANCE AS A COURTESY TO YOU. IT IS YOUR RESPONSIBILITY TO INSURE THAT ALL CLAIMS ARE PAID IN FULL WITHIN A SATISFACTORY PERIOD OF TIME.

Information will be provided for self submission to your medical insurance as well as secondary insurance’s. We will consider billing a secondary insurance only in the case of double coverage through the same company.

It is the insured(s) responsibility to make sure claims are paid in full no later then 90 days from your date of service. If insurance coverage does not provide payment for all charges incurred for treatment rendered by Dr. Stephen Stein, the patient will be responsible for any balance, co -payments, deductible, coinsurance or services not covered by plan. It is your responsibility to make sure your account is settled no later than 90 days from the service date.

In the event an account becomes over 90 days delinquent, I understand that Dr. StephenM.Stein is entitled to send my account to an outside collection agency. If this action is necessary, I agree to pay all additional collection fees, in addition to my account balance. It is my responsibility to follow up with my insurance to make sure payment has been made to Dr. Stein within the stated time frame.

I understand and agree that if I fail to resolve my account in the agreed to period, I will be responsible for all additional cost of collecting monies owed, including court costs, collection agency and attorney fees, plus interest thereon at 18% (eighteen percent) on all such amounts outstanding.

There will be a $50 fee added to all returned checks.

Our fees are comparable to usual and customary for this area and specialty. Most insurance companies pay from their “U & C” schedule. In turn, unpaid portions of our fees are the responsibility of the patient. We will balance bill you for the remainder as well as reimburse you for any overpayments. Any monies owed are due upon receipt. We invite you to discuss with us any questions you may have regarding our fees.

Cancellation Policy

Any cancellations or changes of a scheduled surgical procedure(s) require a minimum of 5 working days notice. An appointment cancelled with less then 5 days notice will result in a cancellation fee of 10% of the surgical fees or $500, which ever is greater. Some cancellations may require written notification.

For Insurance Billing: I hereby authorize Dr. Stephen Stein to furnish medical record information to insurance carriers concerning any illness and treatment, and hereby accept responsibility for all fees regardless of insurance coverage.

My signature below indicates that I have read and agree to the terms set above.

Signature______Date______Relationship:______