This Release of Information will remain in effect until terminated by me in writing.
Thank you for choosing James G. Loeser DDS, MD for the highest quality oral, maxillofacial and implant surgical care. To prevent misunderstanding concerning your responsibility regarding payment for services rendered, the following is understood:
Financial Policy: Both a social security number and a credit card on file is required. If you have benefits for the services that were provided, a claim will be submitted to your insurance company, Any remaining balance (resulting from deductible, co-insurance, etc.) is then charged to your credit card on file. After 60 days, unpaid balances will be turned over to a collection agency; the patient and/or patient guarantor is responsible for all collection costs.
PPO Dental/HMO: If you plan to use your insurance benefits, we will require a copy of your insurance card, a driver's license and your social security number. All co-payments are due prior to seeing the doctor. Failure to provide all necessary information may require you to pay in full on the date of the visit or subsequent to treatment. You are responsible for any services that are not a covered benefit under your insurance plan and/or are not considered medically necessary by the insurance company. Patient portions are due the day of surgery. There is a $25 processing fee for filing with your dental insurance. Please note: If services are not a covered benefit in your plan, the fees will not be reduced (per Illinois97th general assembly law SB3242).
PPO Medical: We are out of network with all medical insurance plans. Payment will be due in full for services rendered. If there is a payment issued to us from your insurance company, you will be reimbursed the amount issued.
Medicare: Dr. Loeser is NOT a Medicare provider. Dental services are NOT a covered benefit of Medicare. Fees are due in full the day of services.
Pathology Fees: If a specimen is taken, there will be a separate fee from the pathologist/independent pathology laboratory.
Self-Pay Patients: For patients without insurance, payment is due at the time of service.
Payments: Payments over 30 days are subject to a 3% fee.
Returned Checks: A charge of $50 will be made for all returned checks.
Payment Plans: Payment plans can be arranged PRIOR to services rendered. A credit card must be on file and will be run on specific dates. If your credit card information changes it is YOUR responsibility to contact us with the new information. If your card is declined, the balance will be due in full and the payment plan will be voided.
Appointment Cancellation Fee: If you are unable to keep your appointment, please call at least 24 hours in advance and speak with someone in our office or leave a message. Insufficient notice may subject you to a $20 fee.
My signature below indicates my understanding and full responsibly for the balance on my account for any professional services
