Patient Registration & Health History

In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and applicable Pennsylvania law, I understand and consent that video recording may occur within Keystone Oral Surgery & Implant Center for patient safety, security, quality assurance, training, and operational review.

Video recording may occur in both clinical and non-clinical areas, including but not limited to hallways, consultation areas, operating rooms, recovery rooms, and treatment areas, as permitted by law.

I acknowledge that video recordings may incidentally capture Protected Health Information (PHI) and are maintained, accessed, used, and disclosed in compliance with HIPAA, the clinic's Notice of Privacy Practices, and applicable Pennsylvania law. Recordings are used solely for authorized internal purposes or as otherwise permitted or required by law.

Thank you for choosing Keystone Oral Surgery Associates. Please review and acknowledge the following financial policy prior to treatment.

Payment is due at the time services are rendered. We accept cash, check, credit cards, and applicable insurance for contracted providers. Patients are responsible for understanding their insurance coverage, including network status, benefits, exclusions, pre-authorization requirements, and out-of-pocket costs.

We will attempt to verify insurance coverage; however, it is your responsibility to provide current and accurate insurance information. Failure to do so may result in full financial responsibility.

For contracted insurance plans, we will bill your insurance after collecting applicable copayments and deductibles. Any remaining balance will be billed to you after insurance processing (typically 45–60 days). If we are out-of-network, full payment is due at the time of service.

Photo ID and proof of payment are required. Copies of your ID and insurance card will be kept on file. Insurance verification does not guarantee coverage or payment.

This policy is designed to respect both the clinic's time and other patients' needs.

IV Sedation Appointments:

• A 72-hour advance notice is required for cancellation or rescheduling.
• A fee of $150 per 30 minutes of scheduled appointment time will be charged for late cancellations or no-shows.

Rescheduling After a No-Show:

• Appointments can be rescheduled after a 2-week waiting period.
• A $150 fee must be paid at the time of rescheduling.
• The doctor will see you on the rescheduled date if time permits.

Pre-Sedation Instructions:

• All necessary forms and instructions will be provided during your consultation.
• Failure to follow pre-sedation instructions will result in rescheduling.
• A fee of $150 per 30 minutes of the original appointment time will apply.

We understand that emergencies may arise. Please contact our office immediately if you need to cancel or reschedule.