Patient Financial Policy

Purpose

Dedicated time from our physicians, clinical staff, clinic rooms, procedure rooms, operating rooms, equipment, and associated resources is reserved exclusively for each patient. Because these resources are limited and often cannot be reassigned on short notice, cancellations, late changes, and missed appointments may result in financial losses to the practice, facility, and associated providers.

This patient-facing enterprise policy establishes requirements regarding payment, scheduling, cancellations, rescheduling, refunds, late arrivals, insurance responsibilities, and patient financial obligations for services provided by AOS practices and facilities.

By scheduling an appointment, procedure, or surgery with the practice, the patient acknowledges and agrees to the terms outlined below.

Payment Policy

Payment is required before services are rendered unless otherwise required by applicable law, payer agreement, or practice policy.

Office Consultations and Follow-Up Visits

• Office visit fees are due in full at the time of scheduling.
• Office visit fees are non-refundable after the appointment has been scheduled or when forfeiture applies under this policy.
• These fees compensate the practice for reserved physician time, clinical evaluation, review of records and imaging, medical decision-making, treatment planning, and professional services associated with the visit.

For appointments covered through insurance or provided without an upfront visit fee:

• Cancellation and rescheduling fees may apply as outlined in the Cancellation and Rescheduling Policy.
• The practice may consider exceptions for documented medical emergencies or other extraordinary circumstances.

In-Office Procedures

• The patient's estimated financial responsibility, including applicable deductibles, copayments, coinsurance, or self-pay amounts, is due in full no later than fourteen (14) calendar days before the scheduled in-office procedure.
• If the procedure is scheduled fewer than fourteen (14) calendar days in advance, payment is due in full at the time of scheduling.
• The procedure may be rescheduled if required payment has not been received by the applicable payment deadline.
• If professional services, supplies, equipment, or other resources have already been provided, charges associated with those services remain the patient's responsibility.

ASC, Hospital, and Operating Room Procedures

To reserve a surgery date, a 50% deposit of the patient's estimated financial responsibility is due at scheduling. The remaining estimated balance is due no later than twenty-one (21) calendar days before surgery.

If surgery is scheduled fewer than twenty-one (21) calendar days in advance, the estimated balance is due in full at the time of scheduling.

Failure to pay the remaining balance by the due date may result in cancellation of surgery and release of the reserved operating room time.

Insurance and Financial Responsibility

As a courtesy, the practice may verify insurance benefits and provide an estimate of anticipated patient responsibility. Insurance benefit information is provided solely as an estimate and is not a guarantee of payment by any insurance carrier.

The patient remains financially responsible for applicable charges not paid by insurance, including:

• Deductibles
• Copayments
• Coinsurance
• Non-covered services
• Services denied by insurance
• Benefit limitations
• Coordination of benefits adjustments

Patient financial responsibility remains applicable regardless of insurance claim status, prior authorization status, benefit verification, or claim processing, subject to applicable payer agreements and law.

If insurance pays more than the patient's responsibility, any resulting credit balance will be refunded or applied as appropriate and in accordance with applicable law.

If insurance pays less than estimated or denies payment after treatment, the patient remains responsible for the outstanding balance.

Financial Estimates

Financial estimates may change based on:

• Clinical findings
• Services actually provided
• Facility charges
• Anesthesia charges
• Pathology services
• Laboratory services
• Implants
• Supplies
• Insurance determinations
• Changes in treatment requirements

The patient remains responsible for applicable charges associated with services provided and resources committed on the patient's behalf.

The patient is responsible for providing accurate and current demographic, insurance, and billing information. Delays, denials, or additional balances resulting from inaccurate, incomplete, or untimely information remain the patient's responsibility.

Certain services related to treatment may be provided by independent third-party providers, including anesthesia providers, pathology laboratories, radiology services, laboratory services, and facility services. These providers may bill separately, and the patient may have separate financial responsibility.

The patient agrees to remain responsible for all unpaid balances. The practice reserves the right to pursue lawful collection of unpaid amounts, including referral to a collection agency or other legal remedies as permitted by applicable law.

Cancellation, rescheduling, or discontinuation of treatment does not relieve the patient of responsibility for amounts owed for professional services already provided, resources already committed, or other amounts due under this policy.

Administrative Services and Records Fees

Requests for administrative services that are not included as part of routine patient care may be subject to a separate fee. These services may include completion of disability, Family and Medical Leave Act (FMLA), employment, insurance, school, travel, legal, or other forms and documentation requested by the patient or an authorized third party.

Any applicable fee will be disclosed before the requested service is completed and is due in advance. Administrative fees generally cannot be submitted to or reimbursed by health or dental insurance. Expedited requests may be subject to an additional fee when expedited completion is available.

Requests for copies of medical or dental records, imaging, or other patient information will be processed in accordance with applicable federal and state law. Any copying, preparation, delivery, or media fees will not exceed amounts permitted by applicable law and will be disclosed when applicable. No fee will be charged where prohibited by law.

Current administrative service and records fees may be maintained in a separate fee schedule and may vary by request type, format, urgency, treatment location, and applicable law.

Cancellation and Rescheduling Policy

Office Consultations and Follow-Up Visits

• Rescheduling more than seventy-two (72) hours before the scheduled appointment allows the payment to be transferred to one future appointment.
• Cancellations within seventy-two (72) hours, failure to appear ("No Show"), or repeated scheduling changes may result in forfeiture of the payment associated with the appointment.
• For visits provided without an upfront fee or billed through insurance, a $200 administrative rescheduling/no-show fee may apply before another appointment is scheduled when permitted by applicable law and payer requirements.
• The $200 administrative rescheduling/no-show fee is separate from any applicable insurance copayment, deductible, coinsurance, or other patient responsibility.
• Patients who cancel, reschedule within seventy-two (72) hours of their scheduled appointment, or fail to attend ("No-Show") an orthodontic, hygiene, nutrition, myofunctional therapy, or psychiatry appointment may be assessed a $200 administrative cancellation, rescheduling, or no-show fee. This fee must be paid in full before a new appointment will be scheduled, except where prohibited by applicable law or payer requirements.

In-Office Procedures

More than fourteen (14) calendar days before the scheduled procedure:

• The procedure may be rescheduled based on provider availability.
• Payment may be transferred toward the rescheduled procedure.

Within fourteen (14) calendar days of the scheduled procedure:

• Amounts paid toward the patient's estimated financial responsibility may be retained to offset unrecoverable costs associated with the cancellation, including reserved provider time, clinical staffing, supplies, equipment, and other resources committed for the procedure.
• Payment in accordance with this policy will be required before another procedure date is scheduled.

ASC, Hospital, and Operating Room Procedures

Because surgery requires advance reservation of physician time, operating room capacity, facility resources, anesthesia services, clinical personnel, equipment, and administrative coordination, cancellation or rescheduling within twenty-one (21) calendar days of the scheduled surgery date may result in the surgical reservation deposit being retained as liquidated damages to offset the resulting losses.

These losses — including reserved surgeon and operating room time, facility and staffing resources, and the lost opportunity to schedule another patient during the reserved surgical time — are difficult to calculate precisely at the time surgery is scheduled. The patient agrees that the reservation deposit represents a reasonable estimate of these anticipated losses and is not intended as a penalty. The practice will not retain amounts in excess of that reasonable estimate.

A new 50% reservation payment will be required before another surgery date is scheduled.

Facility-specific cancellation, late-arrival, and financial terms applicable to the ASC or hospital will be provided separately at the time of surgical scheduling.

Late Arrival Policy

Prompt arrival is necessary to maintain patient safety, operating room efficiency, and the schedule for all patients.

Office Visits and In-Office Procedures

Patients arriving more than fifteen (15) minutes after their scheduled appointment or procedure time may be required to reschedule.

If rescheduled:

• A $200 rescheduling/late arrival fee may apply.
• A new appointment or procedure date must be scheduled.

ASC, Hospital, and Operating Room Procedures

Patients arriving more than thirty (30) minutes after the scheduled arrival time may have their surgery cancelled at the physician's discretion if proceeding would interfere with:

• Patient safety
• Anesthesia requirements
• Operating room efficiency
• Facility requirements
• Other scheduled cases

If surgery is cancelled due to late arrival, the twenty-one (21) day surgery cancellation policy applies, and amounts paid may be retained as liquidated damages as outlined above.

Practice-Initiated Rescheduling or Cancellation

The practice reserves the right, in the physician's clinical judgment, to postpone, reschedule, or cancel appointments, procedures, or surgeries when medically necessary, when proceeding would not be safe or appropriate, or when required by facility, regulatory, anesthesia, or operational requirements, including circumstances beyond the practice's reasonable control such as equipment failure, facility issues, weather events, public health emergencies, or staffing shortages.

Reasons may include, but are not limited to:

• Changes in patient health status
• Acute illness, infection, or other conditions affecting safety
• Medical clearance concerns
• Anesthesia considerations
• Facility requirements
• Equipment availability
• Regulatory requirements
• Other clinical circumstances

The practice may also modify scheduling when necessary to maintain safe and efficient operations.

When the practice initiates postponement, rescheduling, or cancellation, payments will be handled in accordance with applicable law and the circumstances requiring the change.

Travel and Accommodations

Patients who travel for consultations, procedures, or surgery are responsible for arranging and paying for their transportation, lodging, meals, lost wages, childcare, and other travel-related expenses.

Patients are encouraged to use refundable or changeable reservations and should not make non-refundable travel arrangements until the appointment or surgery date has been confirmed by the practice and, when applicable, the facility.

Appointment, procedure, and surgery dates may be postponed, rescheduled, or cancelled because of changes in the patient's health, medical-clearance or anesthesia requirements, facility availability, equipment issues, weather, public-health events, regulatory requirements, staffing limitations, or other clinical or operational circumstances.

To the extent permitted by applicable law, AOS is not responsible for airfare, lodging, transportation, lost wages, cancellation charges, or other incidental or consequential expenses resulting from a postponed, rescheduled, or cancelled appointment, procedure, or surgery. Payments made directly to AOS will be handled under the applicable provisions of this Patient Financial Policy.

Treatment Plan Changes

The patient understands that treatment plans may change based on:

• Clinical findings
• Medical necessity
• Intraoperative findings
• Changes in health status
• Insurance requirements
• Other circumstances affecting medical care

Additional services, procedures, or treatment not included in the original estimate may result in additional charges.

Refund and Outcome Policy

Medicine and surgery are not exact sciences. Although every effort is made to achieve the best possible medical and surgical outcome, no guarantee or warranty, express or implied, is made regarding the results of any examination, treatment, procedure, or surgery.

Patients understand that medical, functional, and cosmetic outcomes vary among individuals. Additional treatment, revision procedures, adjustments, or future care may sometimes be recommended but are not guaranteed.

Payments made to the practice compensate physicians and staff for professional services provided, including:

• Consultation
• Evaluation
• Diagnosis
• Medical decision-making
• Treatment planning
• Procedures performed
• Other services rendered

Payments may also include amounts associated with reserved appointment time, procedure time, operating room time, facility scheduling, staffing commitments, and other resources allocated for the patient's care.

Payments are not contingent upon achieving any particular medical, surgical, functional, or cosmetic outcome.

Refunds generally will not be issued because:

• A patient is dissatisfied with the outcome of treatment.
• A desired medical, functional, or cosmetic result is not achieved.
• A patient elects not to proceed after professional services have been provided or resources have been committed.
• Insurance reimbursement differs from the original estimate.
• Additional care, revision, or future procedures are recommended.

Refunds will be issued when required by applicable law, payer requirements, or when an account has a credit balance.

If a credit balance or refund is otherwise due to the patient, the practice reserves the right to first apply that amount toward any outstanding balance owed by the patient to the practice — including balances from other appointments, procedures, surgeries, no-show or late-arrival fees, administrative fees, or other amounts due under this policy — before issuing any remaining refund to the patient.

Home Sleep Study Equipment

Patients who receive a home sleep study device from the practice must return the device within seven (7) calendar days after completion of the study.

Pattern of Missed Appointments

Repeated missed appointments or no-shows may result in dismissal from the practice in accordance with applicable law and continuity-of-care requirements.

Outstanding balances, missed appointment fees, late arrival fees, and required reservation payments must be resolved before additional appointments, procedures, or surgeries are scheduled.

Exceptions

The practice may consider exceptions for documented medical emergencies or other extraordinary circumstances. Supporting documentation may be requested.

Any waiver of fees, transfer of payments, or rescheduling without application of this policy is at the discretion of the practice and does not constitute a waiver of future enforcement.

If any provision of this policy is determined to be unenforceable or invalid, the remaining provisions shall remain in full force and effect to the fullest extent permitted by law.

Patient Acknowledgment

The electronic website copy is provided for convenient access to the policy. Any patient signature or acknowledgment required by AOS will be collected through the applicable patient-facing workflow.