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Oral Surgery Financial Policy Information


Thank you for choosing Heart of Texas Oral and Maxillofacial Surgery, PLLC. as your oral surgery care provider. We are committed to providing you and your family a safe and comfortable experience. The following is a statement of our financial policy, which we require you to read and sign prior to any treatment.

Patient With Insurance – I understand my insurance may only pay a portion of the cost of my treatment. My portion is due at the time of treatment. The amount collected at the time of treatment is only an estimate. This estimate is based on information received over the telephone or online from the insurance company. This is not a guarantee of benefit or payment. As a courtesy, the office will submit a claim on my behalf; however, I understand I am ultimately responsible for the total amount due. If the insurance company pays less than anticipated, or denies my claim, I will receive a statement and it will be my responsibility to pay the remaining amount due. In the event my insurance company does not make payment within 60 days, I will be notified. If payment is not received within 60 days, 18% APR will begin to accrue. If the insurance company pays more, I will be mailed a refund. To help us in assisting you, we ask that you keep us informed of any change to your insurance.

Patient Without Insurance – I understand payment in full is expected at the time of treatment and some procedures may require a deposit prior to treatment date.

Methods of Payment – Cash, Check, Visa, Mastercard, American Express, and Discover.

Returned Checks – I understand a $35.00 fee will be added to my account balance for any returned checks.

Service Fee – I agree that a $35.00 collection fee will be added to my balance owed should my account be forwarded to a collection agency for recovery. I understand that any attorney and court fees incurred in the collection process will also be guaranteed by me.

Minor Patient – A patient age seventeen or younger is considered a minor. An adult or guardian must accompany the patient for treatment. The adult accompanying the patient and the parent(s) are financially responsible for the account. In the event the parents are divorced, the parent accompanying the minor is financially responsible at the time of service, regardless of the divorce decree. Settlement must be resolved between the parents. Ultimately, both parents are responsible for the minor’s healthcare unless the divorce decree specifically states otherwise. For unaccompanied minors, non-emergency treatment will be denied.

Cancellation Policy: Cancellations for consultations and follow-up visits must be made 2 business days prior to your scheduled appointment. Cancellations made less than 48 hours in advance may  incur a $35 missed appointment fee.  Cancellations for surgery procedures within 7 days of the scheduled procedure will  be subject to  a cancellation fee.

Authorization to Release Information – I hereby authorize Heart of Texas Oral and Maxillofacial, PLLC, to release information acquired in the course of examination and/or treatment for insurance claims processing and/or legal purposes.

Please click here if you would like a copy of this contract for your records