As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
After the patient’s dental assessment, it may be recommended that the patient’s treatment be completed under general anesthesia at Memorial University Medical Center. The reasons for this recommendation may include: extensive treatment needs, special health care/medical needs, and behavioral management or coping/cooperation difficulties.
To help you navigate your medical and dental benefits, we will gladly verify your insurance by sending a pre-authorization and we will provide you with an estimate for your out-of-pocket dental expenses. Please provide our office with all dental and medical insurance information, as well as waiver information, so that the proper paperwork can be submitted and processed prior to the patient’s treatment date.
The fee structure is such that there are 3 separate fees: one for the hospital and facilities, one for anesthesia, and one for the dental treatment. Your medical insurance should help cover portions of the first two fees (which will be billed by Memorial University Medical Center), and your dental insurance/dental treatment waiver will cover all/portions of the dental care (which will be billed through the dental office of Dr. Steven Berwitz). The patient is responsible for all non-covered expenses prior to treatment. To avoid cancellation/rescheduling of treatment, payment for dental services is due one-week prior to the patient’s scheduled appointment.
Anesthesia will be handled by an anesthesiologist at the Memorial University Medical Center. Anesthesia requires a history and physical (aka H&P or "pre-op") from the patient’s primary care physician signed and dated the day prior to the scheduled dental treatment date. It is important to contact the patient’s primary care physician soon after the patient’s initial dental assessment to verify if medical testing/clearance is required by any medical specialists (i.e., cardiologist, pulmonologist) prior to treatment.
I have read the above conditions of treatment and payment and agree to their content.