PATIENT FINANCIAL AGREEMENT & PAYMENT TERMS
Please review and sign the following terms and conditions for the payment of sedation/anesthesia fees before your appointment.
Fee-for-Service & Payment Due Date
- Payment at Time of Service: This practice operates strictly on a fee-for-service basis. Payment in full is required at the time sedation or anesthesia services are rendered.
- Pre-Treatment Payment Mandate: For all planned sedation or anesthesia, payment must be processed online prior to entering the anesthesia suite. Sedation or anesthesia will not be administered or initiated without full payment collected beforehand.
- Accepted Forms of Payment: We accept cash, major credit cards (Visa, MasterCard, American Express, Discover), personal checks, and approved third-party financing.
Complete Insurance Non-Participation Policy
- Out-of-Network Status: This practice does not participate in any dental nor medical insurance networks, is not a contracted provider with any managed care plans, and does not accept insurance assignment or reimbursement.
- Patient-Managed Claims: Our practice will not submit claims, estimates, or pre-authorizations to insurance companies on your behalf. If you carry dental insurance and wish to seek reimbursement, you are strictly responsible for filing your own out-of-network claims.
- Direct Relationship: Any and all post-procedure claims, inquiries, denials, or reimbursement disputes must be handled strictly between the policy holder and the insurance company. The balance owed to Han Anesthesiology remains unchanged regardless of your insurance policy's out-of-network benefits or determinations.
Scope of Fees & Emergency Hospitalization Disclaimer
- Limitation of Fees: The fees collected by Han Anesthesiology cover strictly the administration and monitoring of anesthesia/sedation by our clinician during your scheduled session, as well as routine recovery check-ins within 48 hours of the appointment.
- External Emergency Facilities: Clinical risks, including the rare possibility of emergency transfer or hospitalization, are outlined in detail within your clinical Informed Consent Form. In the event of an emergency requiring transfer to an outside hospital or emergency care facility, the policyholder is strictly responsible for all external facility fees, ambulance charges, and hospital bills. Han Anesthesiology is not liable for costs incurred outside of our independent provider fees.
Delinquent Accounts & Administrative Policies
- Past-Due Balances: While payment is required upfront, any administrative balances remaining unpaid past thirty (30) days from the billing date may be subject to a late fee of 1.5% monthly interest
- Collections: Balances left unpaid after ninety (90) days may be referred to an external collection agency. You will be responsible for any collection or legal fees incurred during this process.
- Patient Records Notice: In strict compliance with Texas law, please note that while we enforce strict payment-before-service policies, our office will not withhold your patient records due to an unpaid balance.
Post-Treatment Care and Consultations
- Included Services: Fees charged cover the specified diagnostic and therapeutic procedures explicitly listed on your treatment plan.
- Routine Recovery Check-Ins: The fee collected at the time of service fully covers your scheduled anesthesia or sedation procedure, as well as routine, immediate post-operative phone consultations or follow-up calls to address recovery questions within 48 hours of the appointment.
- Subsequent Billable Consultations: Any unrelated clinical consultations, requests for diagnostic reviews, or evaluations sought after the immediate recovery window will constitute a separate clinical appointment and will be subject to standard fees.
Itemized Billings & Plain Language Requests
- Plain Language Disclosure: You have the right to request a complete, itemized statement of charges at any time.