SALEM LASER AND SURGERY CENTER
1330 Commercial St. SE
Salem, OR 97302
503-763-1973

FEE ESTIMATE

PATIENT NAME:

PLANNED PROCEDURE:

PROCEDURE DATE:

This information tool is to be considered an approximation of facility fees for the procedure identified above and does not cover fees for procedures not scheduled on this date.

SURGEON FEES
Billed seperately by your physician.

ANESTHESIA FEES
Billed seperately by your anesthesia practitioner; questions may be directed to: Anesthesia Associates Northwest, LLC
1-877-222-4217

SURGERY CENTER FEES
The facility billing office will contact you prior to surgery to let you know what your estimated patient portion will be. Billing questions may be directed to the CBO at 1-855-887-4997.

Co-payments are due at the time of your procedure. Co-payments accepted by check, credit card, or exact amount of cash only.

INSURANCE BILLING & STATEMENTS
We participate with many plans and will bill your insurance carrier accordingly. We also accept Medicare assignment.

Depending on your insurance plan and their payment guidelines, you will receive a statment after your surgery. Check your statement for the "Amount Due" box. That is the balance due by you. Call 1-855-887-4997, if you have questions about your surgery billing.

ASK US
Please do not hesitate to call us with any questions or comments you may have. We will assist you as best we can.