Financial Options for Our Patients
As validated by my signature below, I understand and agree to the following:
All patient balances are due at the time of service. Should a balance accrue on your account a statement will be sent and payment is due, in full, by the date on the statement. If the payment is not paid within 30 days, interest and/or a billing fee may be applied to the entire balance. Subsequent revised statements are due upon receipt. Accounts unpaid after the 90-day due date will be sent for collection. A returned check fee will be applied and must be paid for each check payment returned by the bank.
Patients with Insurance: Our office will gladly file with all insurances companies to help our patients get the maximum benefit available. Most dental plans do not cover 100% of treatment costs. We require payment of your deductible and estimated coinsurance (copay) on the day of service. We can make no guarantee of any estimated or actual amounts.
Treatment plans may require adjustments. Pretreatment estimates are based on information from your insurance company and initial treatment plans. We are not responsible for inaccurate information provided by the insurance company.
Note: Dental insurance coverage is a negotiated contractual agreement between you or your employer and the insurance company, but the ultimate responsibility for all charges lies with you. If, after 90 days, the insurance company has not paid the claim, you will be responsible for the total balance.
Outside Financing: We have an outside financing option through Care Credit that offers interest free, monthly payment plans to patients with good standing credit. Go to CareCredit.com for more details.
Patients without Insurance: We are happy to offer a 5% payment adjustment for those without insurance who pay with cash or check at the time of service. You may want to consider our Autumn Dental Membership Club; ask staff for more details.
I hereby authorize direct payment to the Autumn Dental of the dental insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. In the case of payment default, I understand that I am responsible for all processing fees, collections costs, and reasonable legal fees incurred to acquire the outstanding balance. I grant the right to the dentist to release my dental/medical history and other information about my dental treatment to third party payors and/or other health professionals by any method, including electronic transfer.