conditions for treatment
We strongly feel that all patients deserve from us the VERY best medical/dental care that we can provide. Further, we feel that everyone benefits when definitive financial arrangements are agreed upon.
Please read the following:
Assignment of Benefits:
- I authorize this office to release or receive any information necessary to expedite insurance claims.
- I authorize this office to bill my insurance company directly for their services.
- I authorize payment directly to Dr. James C. Wallace or Dr. Thomas B. Padgett of any insurance benefits otherwise payable to me.
This office participates in Medicare, and we agree to accept Medicare approved charges. However, you should realize that Medicare may determine that a particular service, although it would otherwise be covered by medical/dental insurance, is “not considered reasonable and necessary” under Medicare program guidelines. Therefore, Medicare may deny payment for any of the following reasons:
- The procedure is considered dental surgery.
- The procedure involves treatment of the teeth or gums
- The procedure involves treatment of the supporting tissue of the teeth or gums.
The patient is hereby informed in accordance with Section 32.1-45.1 of the code of Virginia, 1950 as amended, that if the provision of health care services to you at our office directly exposes any person or health care provider, to the patient’s body fluids in any manner which may transmit immunodeficiency virus or HIV or Hepititis B or C virus, then the patient shall be deemed to have consented to testing for infection and to release the results of such tests to the health care provider.
I understand I am fully responsible to Dr. Wallace and Dr. Padgett for charges not covered by insurance or Medicare. I assume responsibility for all charges provided on my behalf or any of my dependants. An interest rate of 1.5% is added to any remaining balances after 60 days.
In the event my account is referred to an attorney for collection, I agree to pay attorney’s fees in the amount of 33.3% of the total balance due, as well as all court costs associated with the collection of my account. There will be a $30.00 charge on all returned checks.