At Northtowns Oral & Maxillofacial Surgery, PLLC, we make every effort to provide you with the finest care and the most convenient financial options. To accomplish this we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures.
Northtowns Oral & Maxillofacial Surgery, PLLC
FINANCIAL RESPONSIBILITY STATEMENT
Dr. Glen Donnarumma and the staff at Northtowns Oral & Maxillofacial Surgery, PLLC are dedicated to providing oral and maxillofacial surgery procedures in a caring and comfortable environment. We strive to ensure that all of our patients receive the care and attention that they deserve. We would like each patient to understand our office policies and procedures including our financial policy. Please feel free to ask us any questions if you are unclear about what is stated below.
The dental benefit plan we participate in is Delta Dental. We do not participate in any medical insurance plans.
If you have a dental benefit plan other than what is listed above, we ask that you pay for services in full at the time they are rendered and then, we will gladly submit your claim to your insurance company so that they may reimburse you for any covered services. Please understand that some dental benefit plans require a medical claim to be sent for denial so this may prolong the reimbursement timeframe.
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All services will be billed to the responsible benefit plan. If for any reason the claim is rejected and/or denied, you will be responsible for payment. After the insurance payment is received, any balance that is the patient’s responsibility is due immediately upon receipt of a bill. Please be advised that the parent bringing a child in for treatment is responsible for payment at the time of service regardless of personal circumstances. Whoever is signing this form must be present at the time of appointment and no digital signatures will be accepted.
The staff at Northtowns Oral & Maxillofacial Surgery are sensitive to the fact that it may be difficult for all patients undergoing more extensive and costly procedures to pay at the time of service. If this situation pertains to you, or if you are uninsured, we do offer third party financing through CareCredit. Our staff will be happy to explain how this works when you come in for your consultation. Please note that we only offer the 6 month no interest plan. If you would like to obtain information about CareCredit prior to your visit, please feel free to visit their website at www.carecredit.com
We accept the following methods of payment: Visa, Mastercard, Discover, American Express), check, money order, cash or Care Credit.
I authorize payment directly to Northtowns Oral & Maxillofacial Surgery, PLLC for services rendered unless otherwise payable to me under the terms of my insurance. I agree to all terms listed and stated above. I understand that in the case of non-payment, that I will be responsible for any collection and/or attorney fees that may be involved in the collection of my debt.
Please be advised that failure to show for a surgery appointment will result in a $100 no show fee, and failure to show for a consultation appointment will result in a $25 no show fee. Please provide our office with 48 hours’ notice of cancellation if you are not able to make your appointment. Thank you for your cooperation!!