Atlanta Oral & Facial Surgery - Financial Policy Form

Financial Policy PREVIEW

Details Of Patient

First Name:		Last Name:
Date of Birth :		Phone Number :
Email :

As a courtesy, Atlanta Oral & Facial Surgery files claims to your insurance company on your behalf. Our staff attempts to verify accurate coverage, eligibility, and benefits, in addition to estimating your coinusrance based on those quoted benefits. However, telephone estimates are not legally binding and often misquoted; therefore: ALL TELEPHONE VERIFICATIONS ARE AN ESTIMATION AND NOT A GUARANTEE OF COVERAGE OR BENEFITS. To maximize your benefits and to provide our highest level of customer service, AOFS would like to make you aware of these helpful items:

Provide AOFS with all insurance information to avoid paying IN FULL. Should this information not be provided at (or prior to) the Consultation, you will be responsible for all fees related to your Consultation. If the information is still unavailable 24 hours prior to Surgery, our policy is to collect for your surgery in full and AOFS not file any claim on your behalf.

Check with your insurance company regarding :

(1) Benefits. Most insurance companies only verify general benefits. AOFS can provide the procedure and diagnosis codes, upon request. AOFS encourages submitting a Pre-Estimate of Benefits. This may take the insurance 6-8 weeks to process.

(2) In-Network Participation. Treatment rendered at an in-network provider indicates the doctor’s office has agreed to a contractual sharing of healthcare expense by reduced rates.

(3) Status of your claim. Your involvement with the insurance company decreases the processing time. Claims unpaid by the insurance company will be your responsibility 120 days after service.

(4) Final Reimbursement. All reimbursement decisions are determined by your insurance company, and made strictly in accordance with plan provisions and patient eligibility at the time of service. AOFS is not responsible for plan provisions.

After your date of service :

(1) Insurance companies often process provider payments in bulk; therefore, it is likely the insurance company will send your copy of the EOB weeks before AOFS receives it. Please allow 4-6 weeks for AOFS to receive and process your EOB.

(2) Insurance claims (especially when filing to secondary insurance) can take up to 30-90 days to process. If you receive a bill from AOFS less than 30 days after your consult or surgery, please disregard as our system sends statements automatically every 30 days. Statements received after 30 days may be owed.

(3) Separate billing from an Oral Pathology Lab is possible. We provide them with your insurance information, but we are not responsible for how they file or even if they file. You are responsible for their fees should insurance not cover it.

All financial obligations (coinsurance, copay, full fees) must be paid in full the day of service. Should you need assistance with your payment, we suggest Care Credit at 1-866-893-7864 or www.carecredit.com

FINANCIALLY RESPONSIBLE PARTY - Must be present at appointment

First Name :

Last Name :

Date of Birth :

Marital Status :

Sex :

Address :

Apt :

City :

State :

Relationship to Patient :

Driver’s License # and State / Social Security #

Daytime Phone # :

Evening Phone # :

Home

Cell

Work

OK to leave Message

Home

Cell

Work

OK to leave Message

I attest the person named above has agreed to be financial responsible for all fees and coinsurances related to services rendered at AOFS. In the event this obligation is not fulfilled, I fully and knowingly assume financial responsibility.

Patient Signature

Apr 12,2026
( IP:' 216.73.216.5 ' )

DATE & IP ADDRESS

Patient Signature

Apr 12,2026
( IP:' 216.73.216.5 ' )

DATE & IP ADDRESS

Preferred Payment Method :

Cash

Check

Credit Card

Financing (Care Credit)

Other :

Financial Policy

Patient Details

FINANCIALLY RESPONSIBLE PARTY - Must be present at appointment

Financial Policy PREVIEW

Details Of Patient

FINANCIALLY RESPONSIBLE PARTY - Must be present at appointment