Our Office Policy is to provide the best treatment with efficiency. However, due to unforeseen circumstances and/or
emergencies, it is difficult to see our scheduled patients on time. If the Doctor is behind schedule, we will inform you and
reschedule your appointment without penalty if you wish. If you are an emergency patient, we are happy to see you at the
earliest time of the day, but please understand that you may have to wait to be seen.
I understand that Dr. Aldrich Sy/Dr. Brian Hui/Dr. Paul Hall begins treatment with a consultation. The Doctor will need
an x-ray, imagery, and/or other aids in order to recommend me the necessary procedures and services involved in the
treatment. I acknowledge that it is the Doctor’s standard of care for me to have a consultation first before scheduling the
surgery. I understand and acknowledge that the office cannot inform me if I am eligible for the initial visit as frequency
limitations may apply to these services and my dental insurance does not guarantee payment.
I understand that I am fully responsible for the payment of all costs associated with the procedure(s) and service(s)
performed by the doctor and the team. I understand that my dental insurance company does not guarantee payment and
any portion not covered by the insurance will be my responsibility. I acknowledge that any insurance coverage that I have
will be based on a contract between my doctor, the insurance company, and me, the policyholder, and/or my employer.
Since the insurance may not cover 100%, I am required to make a copayment of 20% or more depending on my benefits
and the amount I have available. Should my insurance company pay the full amount, I will be reimbursed, via check, for
the co-payment I paid at the office. I understand that I am also responsible for all fees even if I have dual coverage after
both insurances have paid or denied payment due to “Non-Duplication Policy.” Therefore, I understand and acknowledge
that I am liable for all fees not paid or declined by the insurance company (even after initially approving the services). As
a courtesy to the patient, the doctor’s team will bill my insurance company on the date of service. If for any reasons the
insurance denies payment, I will be responsible for the remaining balance, which will be billed to me after 30 days from
the service date.
If I have no insurance or the doctor is NOT in-network with my insurance company, I am required to make the payments
in full on the day of the service unless I have made prior arrangements with the Doctor.
I hereby authorize insurance payment directly to the treating Doctor. If I wish to have the insurance payment assigned to
me, I will pay the full amount of treatment to the Doctor on the day of surgery. I understand that I am financially
responsible for all charges not covered by my insurance company.
All returned checks are subject to a $50 returned check fee. If an appointment is not cancelled/rescheduled 2 business
days prior to the scheduled date, a $100 charge will apply. Any balance remaining unpaid for 30 days from the last
payment date will accrue a 1.5% interest charge. The office will work with me by arranging a reasonable agreement,
should I have financial difficulty. Any unsettled account balance not payable within 90 days will be assigned to a
collection agency. I understand that I will be liable for a 50% collection-processing fee. (This is a practice that we DO
NOT wish to observe).
I consent to be contacted by the Doctor, a representative of the office, or a collection agency (or agent) for any unpaid
balance by mail at any address that I provided the office or by facsimile, phone number (cell phone or landline), or email.
By California Law, all minors MUST be accompanied by a parent/legal guardian for ALL appointments.
