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MOORESVILLE ORAL SURGERY
BUSINESS FINANCIAL POLICY
We would like to thank you for choosing Mooresville Oral Surgery for your health care needs. It is
our goal to provide high quality, compassionate, and cost-effective health care to our patients. Our
main concern is that you receive the proper and optimal treatment to restore and maintain your
health. Part of this care includes a financial policy geared to accommodate each patient individually.
Please read the following policy and, if you have any questions, do not hesitate to ask our office
manager.
As a courtesy, we do accept most insurance plans. We require that you present us with both your
medical and dental insurance cards prior to seeing the doctor in order for us to bill the insurance
company(s) directly. We ask in return that any deductibles, co-pays, co-insurances, or non-covered
services be paid for at the time of service. As the patient, you are ultimately responsible for any and
all services provided. If, for some reason, your insurance company has not paid your balance in
full within 30 days, we ask that you contact them directly to expedite the claims payment process.
It is to your advantage to become involved with this process to settle any disputes the insurance
company may have. Failure to do so may result in your account becoming delinquent. Please
remember that your policy is a contract between you, your employer, and the insurance company.
Our relationship is with you, NOT your insurance company.
Medical and Dental Insurance: We will verify with your insurance company(s) whether or not your
treatment will be covered and what the approximate cost of the treatment will be. Any information
quoted to us by the insurance company is not a guarantee of coverage and/or payment. The cost of
your treatment will be calculated according to the information we obtain from the insurance
company(s). Please keep in mind that this is strictly an ESTIMATE. After the actual claim has been
submitted and processed, you may be responsible for additional charges or you may be due a refund
from our office. Statements for patient balances will be mailed the first week of each month with the
balance due in thirty days. Refunds will be issued once a month, with no exceptions.
Payment Options: We do accept cash, checks, and most major credit cards as forms of payment.
Please note that any check returned unpaid from your bank will be subject to additional collection
fees. We understand that certain financial hardships may arise for some patients. We encourage
you to communicate any such problems immediately so that we can attempt to provide you with
temporary payment arrangements. We will make every effort possible to assist you in the
management of your account balance. Accounts that are delinquent will be placed in collection.
In this unlikely event, you will be responsible for any and all fees that our office incurs throughout
the collection process. These charges will automatically be added to your account.
Lab Work: We utilize Greensboro Pathology and Lab Corp for any specimens collected that require
diagnostic evaluation. Please be advised that you will receive a separate bill from the lab that
performs the testing. Any questions or concerns about your account need to be handled directly with
that particular lab. Please do not call our office with these inquiries.
By signing below you acknowledge that you have read and fully understand our business financial
policy. Again, we would like to thank you for choosing Mooresville Oral Surgery for your health
care needs. We value your trust in us and we appreciate the opportunity to provide your treatment.
Signature: _______________________________________________ Date: ___________________