Willamette Valley Oral and Maxillofacial Surgery, Inc., shares the concern of our
patients about the increasing cost of dental and medical care. Our fees are
comparable to the usual and customary charges made by Oral and Maxillofacial
Surgeons in the area. These charges are based on doctor’s costs, time, and
skill involved. You will be given a written estimate of the charges before
treatment has started.
FOR PATIENTS WITHOUT INSURANCE
Patients without insurance coverage are requested to pay their charges at the time the
service is provided. We accept cash, check, VISA and MasterCard.
FOR PATIENTS WITH INSURANCE
Willamette Valley Oral and Maxillofacial Surgery, Inc., is committed to helping you
maximize your insurance benefits. Because insurance policies vary, we can only
estimate your coverage in good faith but cannot guarantee coverage due to the
complexities of insurance contracts. Your estimated patient portion must be
paid at the time of service. Final determination will be made by the
insurance company once the claim has been processed. As a service to our
patients, we will bill insurance companies for services and allow them 45 days
to render payment. After 60 days, you are responsible for the entire balance,
paid-in-full. We will gladly discuss your treatment with you and answer any questions relating
to your insurance. You must realize, however, that:
1. Your insurance is a contract between you, your employer, and the insurance
company. We are not a party to that contract.
2. Not every service is a covered benefit with all insurance contracts. Some
insurance companies are selective in what services they cover.
3. Services cannot be provided on the assumption that the charges will be paid by
the insurance company; therefore, the patient is responsible for the bill,
regardless of insurance coverage.
If a payment from your insurance company results in a credit balance, a refund
will promptly be sent to you.
RETURNED CHECKS AND COLLECTIONS Accounts with a
returned check will be charged a $35.00 returned check fee. Accounts with
balances over 60 days will be considered overdue and an interest charge of
1.50% monthly (18% annually) will be applied each month. In the event of
default, the outstanding balance shall accrue interest at the rate of 18% per
annum from the date of default until paid in full. If the outstanding balance
is referred to a collection agency, I/we agree to pay, in addition to interest
at the rate of 18% per annum, a reasonable collection agency fee which shall be
35% of the past due balance and all other costs of collection including but not
limited to attorney fees and court costs. I hereby authorize Dr. Eyre to release
any information necessary to process claims with any insurance companies. I
also assign to Dr. Eyre the insurance benefits which are otherwise payable to me
for his charges and direct that insurance payments be made directly to him.
This assignment will remain in effect until revoked by me in writing. A
photocopy of this assignment is to be considered as valid as an original. I
understand that I am financially responsible for all charges whether or not
paid by said insurance. I hereby authorize assignee to release all information
necessary to secure the payment. I hereby authorize Dr. Eyre’s office to release
all chart notes and radiographs to my physician and/or dentist. Please initial
one of the following options and sign where indicated below. I authorize this
office to charge any balance to my credit/debit card after the insurance
company pays their fees.
Signature of responsible party
Your signature indicates that you have read and understand the above information
provided to you and that you will be responsible for payment of fees on the day of
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated.