Online Patient Registration
Online Referral Form
You may refer patients to our office by filling out our secure online Referral Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of patient data is one of our primary concerns and we have taken every precaution to protect it.
Patient Registration
You may preregister with our office by filling out our secure online Patient Registration Form. After you have completed the form, please make sure to press the Complete and Send button at the bottom to automatically send us your information. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.
Notice of Privacy Practices
Your First Visit
Your initial appointment will consist of a consultation explaining your diagnosis and treatment options. Occasionally, surgery can be performed the same day as the consultation. However, a complex medical history or treatment plan will require an evaluation and a second appointment to provide treatment on another day.
Please assist us by providing the following information at the time of your consultation:
- Your surgical referral slip and any x-rays if applicable.
- A list of medications you are presently taking.
- If you have medical or dental insurance, bring the necessary completed forms and insurance cards. This will save time and allow us to help you process any claims.
IMPORTANT: All patients under the age of 19 years of age must be accompanied by a parent or legal guardian at the consultation visit.
Insurance Information
At Midwest Oral Surgery & Dental Implants we make every effort to provide you with the finest care and the most convenient financial options. To accomplish this we work hand-in-hand with you to maximize your insurance reimbursement for covered procedures. If you have any problems or questions, please ask our staff.
Please understand that we are not responsible for your insurance benefits or how your insurance company processes your claim. It is your responsibility to be aware of your own insurance benefits and network differences. Our staff is here to help you. Our Insurance Coordinators will verify insurance eligibility and provide you with a Pre-Treatment Estimate. This Pre-Treatment Estimate is only an estimate of your planned treatment; it is not a guarantee of the patient amount out of pocket due after the procedures have been completed. However, we strongly suggest that you contact your insurance company prior to your consultation in order to understand your specific benefits. Please bring your medical and dental insurance cards with you to the consultation so that we can expedite reimbursement.
As a courtesy to you, we can submit your claim and send you a statement after your insurance has been processed. Please be aware that most insurance companies will respond within four to six weeks. Please call our office and ask for the billing department if your statement does not reflect your insurance payment within that time frame. If insurance does not pay as much as we expect, you are responsible for the remaining balance. By the same token, if your insurance company pays more than we anticipate, we will gladly give you a refund.
If some instances, your insurance company may require a pre-determination of services to help verify your coverage before surgery. If this is required, it may take anywhere form six to twelve weeks depending on your insurance company. Again, this is one reason we ask that you check with your insurance company or your employer so that you will be familiar with your plan benefits before your consultation appointment.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
Financial Information
For your convenience, we accept Visa, MasterCard, Discover, American Express and CareCredit®. 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.
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.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage.
