At Smiles by Delivery, we strive to provide the best and most comprehensive dental care to our patients. We make every effort to keep down the cost of your dental care. One way to keep cost down is to not have a billing department.
By signing below, I understand and agree that:
- A cancelation fee of $99 may be charged for patients who miss or cancel an appointment without 24 hour notice. If a patient cancels three appointments, the patient may be dismissed from our practice and asked to find another dentist.
- Payment is due at time of service. If the financially responsible person is not present at the appointment, payment will be due prior to the appointment.
- A returned check fee of $50 will be applied to my account for each returned check payment.
- Visa, Mastercard American Express or Discover
Credit card payment can be made over the phone or on our secure patient portal, found on our website, www.SmilesByDelivery.com
CareCredit Healthcare Credit Card
- Convenient monthly payment options from CareCredit Healthcare Credit Card. If a payment plan is needed, we suggest applying for CareCredit Healthcare Credit Card. CareCredit can be contacted by:
Our Website: www.SmilesByDelivery.com
Dental Insurance: By signing below, I authorize Smiles by Delivery to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim. I also authorize Smiles by Delivery to appeal on denied claims, on my behalf. It is my responsibility to verify whether my insurance is an out-of-network or in-network plan and if my insurance is active. I understand that Smiles by Delivery can assist me in verifying this information.
PPO Out-of-Network Plans: Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by Smiles by Delivery, not an obligation. I understand that if Smiles by Delivery is out-of-network with my dental insurance plan, my insurance is not accepted as a form of payment.
In-Network Plans: If Smiles by Delivery is in network with my dental insurance, I authorize my insurance benefit to be directed to Smiles by Delivery. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.
Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total.
Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics.
A submission to my insurance provider may be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.
As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. Smiles by Delivery will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments can not be guaranteed because they may need to be modified as needed to accomplish the best result possible.
I have read, understand and agree to the above financial policy for payment of professional fees. I understand that I am ultimately responsible for all fees for services rendered to me and/or my family.
*By signing below, I also consent to any recommended x-rays, teledentistry exams, clinical exams, cleanings (prophy or fullmouth debridement), and fluoride treatments. I understand that a licensed dental hygienist or licensed affiliated practice dental hygienist will be providing the dental hygiene services. Dental hygiene care alone does not take the place of a dental examination or complete dental care. The teledentistry exams, clinical exams, dental diagnosis, treatment plans and restorative treatments are provided by licensed dentists, which may follow the appointment with the hygienist. I also understand that it is Smiles by Delivery's policy that active patients must have their next hygiene appointment scheduled.