Referral and Patient Info

Financial Contract


FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT

Acknownedgement of Non participation with Medicare, Medi-Cal/Denti-Cal, or HMO's /

Acknowledgement of TriCare Non-Covered Services /

Acknowledgement of Receipt of HIPAA Privacy Notice / 



Professional services are rendered to all patients with the understanding that the full amount of the charges are the responsibility of the patient and/or responsible party. Estimates are good for one year for dental surgery and 60 days for facial cosmetic surgery, with the exception of possible changes in insurance policies and fee schedules unless otherwise stated.  If you have insurance, it is your responsibility to provide us with all the insurance policy information, both dental and medical. **VCOMS Does Not Participate in Medicare, Med-i-Cal / Dent-i-Cal, or HMO's**  All copays, deductibles, and noncovered or questionably covered services are to be paid in full at the time of treatment. If your insurance does not pay within 60 days, you are responsible for paying the entire balance in full. If insurance payment is then received from the insurance company, we will reimburse you immediately.  Each insurance company is unique because it may provide different coverages and percentages for services, and might also contain exclusions, limitations, alternate benefits, etc.  We make a good faith attempt to estimate your coverage based upon the resources available by your insurance company.  However, the most accurate way to estimate your coverage is always through a written pre-authorization.  As a courtesy, our office will file a pre-authorization per patient preference on a case by case basis.  This may take up to 6 weeks to be processed by your insurance company.  It is your responsibility to follow-up with the office as necessary to review your pre-authorization once it has been processed, discuss any questions, and to schedule your surgery. However, even insurance verification and pre-authorization is not a guarantee of payment.  If you wish not to or are unable to wait for your pre-authorization, and elect to proceed with your treatment, we may require that you pay for the service in full, or pay your estimated copay.  For our patients without insurance, your payment is due at the time of treatment.  We also offer outside financing for which you may qualify. If you change or cancel your insurance prior to your treatment or your benefits change or rollover, this estimate may not be accurate.  It is your responsibility to inform us of any changes so we can recheck your benefits.  On rare occasions, if you wish to, or it is deemed medically necessary to have a same day procedure, and you do not wish to, or we are unable to wait until we can fully verify your insurance, we will collect 50% of our UCR fee.  We will then file your insurance for you.  Once your insurance has paid, any over payment will be refunded to you.  Any balance will be billed and be due, in full, immediately.  Otherwise, our full Usual and Customary (UCR) fee will be due for any treatment performed. All surgical fees including biopsies do not include the laboratory cost for the pathological examination of the tissue.  Credit can be used in the office for other products or services. Payments are due at the date of service but can be paid in advance.  A 1.5% monthly service charge will be applied to all patient portion balances after 120 days from the date of service.  Claims for advance payments will not be submitted until the date of service.   If you are having a cosmetic procedure done, payment of your surgical fee payment is due in full at your pre-op visit.  If you cancel your surgery after your pre-op visit, there is $750 cancellation fee.  Pre payment for cosmetic products is not refundable. 

By signing this contract I understand and agree that I will not submit (or request that my oral and maxillofacial surgeon submit) a claim to Medicare, Medi-Cal, Denti-Cal, or HMO's or its agents for services provided by Anthony P. Varboncoeur, DDS, & Cortland S. Caldemeyer DDS,even if such services would otherwise be covered.  I agree to be fully responsible, through insurance or otherwise, for payment of services rendered by Anthony P. Varboncoeur, DDS, & Cortland S. Caldemeyer DDS, and I understand that no claims will be submitted to Medicare, Medi-Cal, Denti-Cal, or HMO's Medicare and no Medicare, Medi-Cal, Denti-Cal, or HMO's reimbursement will be provided for these services.  I understand that there are no limits specified by Medicare, Medi-Cal, Denti-Cal, or HMO's as to the amounts that may be charges by the oral and maxillofacial surgeon for services provided.  I understand that Medi-gap plans do not, and other health and medical care insurance plans may elect not to, make payments for such services.  I understand that I have the right to have services provided by other oral and maxillofacial surgeons, or other practitioners for whom Medicare, Medi-Cal, Denti-Cal, or HMO's payment would be made,  and that I am not compelled to enter into private contracts that apply to covered care furnished by other health care professionals who have not opted-out.   I understand that Anthony P. Varboncoeur, DDS, & Cortland. S. Caldemeyer DDS are not excluded from participation in the Medicare program under Section 1128 or the Social Security Act or pursuant to any other legal authority. 

I acknowledge that these services are not a benefit of my health coverage under TRICARE and that I will not receive the benefit of the TRICARE Hold Harmless Policy, which otherwise might apply to me. In addition, I acknowledge that if I have obtained services more frequently than authorized by TRICARE policy, I may be responsible for that professional service. I also understand that if authorization for this care has been denied by TRICARE, or if reimbursement is denied upon submittal of a claim, I agree that I will be personally responsible for the payment  IN FULL of the billed charges for these services.

I acknowledge that I have been given access to, and reviewed the HIPPA privacy compliance policy of Grossmont Oral & Maxillofacial / Facial Plastic Surgery Center available in the reception area to my satisfaction.  I understand a copy of the policy is available should I request it.  

I understand this notice will serve as acknowledgement of my financial agreement & authorization, non-participation with Medicare, Medi-cal, Denti-cal, HMO's,  or Tricare non-covered services, and HIPPA policy for all of my visits to the Grossmont Oral & Maxillofacial / Facial Plastic Surgery Center.