For your convenience we accept Visa or MasterCard. We deliver the finest care at the most reasonable cost to our patients, therefore payment is due at the time service is rendered unless other arrangements have been made in advance. If you have questions regarding your account, please contact us at North Oaks (651) 482-0065 or Roseville (651) 636-2420. Many times, a simple telephone call will clear any misunderstandings.

Please remember you are fully responsible for all fees charged by this office regardless of your benefits availabe though insurance package(s).

We will send you a monthly statement. Most insurance companies will respond within four to six weeks. Please call our office if your statement does not reflect your insurance payment within that time frame. Any remaining balance after your insurance has paid is your responsibility. Your prompt remittance is appreciated. We can make arrangements for a monthly payment plan but that must be done prior to the actual procedure.

Stephen Gadient – Karl Andreasen & Associates

FINANCIAL POLICY

We are committed to providing you with the best possible surgical care and would be happy to discuss our professional fees and financial policy with you. Please ask one of our qualified employees if you have any questions or concerns about our fees, financial policy or your responsibilities.

• All patients must sign this form prior to seeing the doctor.
• If you have insurance, it is your responsibility to determine if our office is a provider for your specific insurance coverage. We are happy to help with the submission of your insurance claim.
• You are responsible for the timely payment of your account.
• If you have insurance and we are participating providers, a down payment is required while your insurance claim is being processed.
• After your insurance has sent reimbursement to our office, you will receive a final bill showing your remaining balance owed to us or the amount to be refunded to you.
• If you do not have insurance, payment is due in full the day of service.

All accounts must be paid within sixty (60) days from the date of service. This includes charges incurred by untimely insurance payments or insurance denials.

We accept personal checks, cash, Visa and MasterCard.

Account balances unpaid after 60 days will be assessed a finance charge of 1 _ % (18% APR).

All accounts unpaid after ninety days will be turned over to a collection attorney unless other payment arrangements have been made. All collection costs are your responsibility. If untimely insurance payments are received while the account is in collections, the responsible party will be liable for all collection fees before any refund will be issued.