Dear patient,
The primary goal of our practice is to provide the highest quality dental care to all our patients. Since our practice also has financial obligations which must be met, we ask you to note the following statements of our financial policy.
Treatment Plans and Estimates:
Treatment plans are merely an estimation of planned procedures diagnosed before treatment and can change as treatment progresses. It is often impossible to predict the exact cost of the treatments until they are rendered.
Methods of Payments: Cash, Check, VISA, Master Card, Discover, American Express, Care Credit, Lending Club and Varidi.
Co-Payments will be collected at check-in prior to you going back to have treatment rendered. If you pre-pay for your co-pay on the date you schedule your appointment, we will honor a 5% discount.
A Credit card will be required to be kept on file for administrative charges and balances 60 days past due. (Rest assured, we will never disclose this credit card information to anyone else and we will notify you before charging your credit card.)
Administrative Charges:
Checks returned by the bank per incident | $35 |
Account balances not paid within 90 days after statement sent | $25 |
Missed and Cancelled appointments without proper notice | $50/hour of appointment time |
Any X-Ray Copy Requests | $20 |
**Collection agency: Patient is responsible for all fees incurred, including attorney & court costs. (Interest rates will be assessed at a rate of 1.0% per month)
Dental Insurance:
- Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexity of insurance contracts.
- As a courtesy to you, we will file dental insurance claims on your behalf if we are in-network with your insurance, but you will be fully responsible for your account if the insurance company does not pay.
- Your insurance plan is a contract between you (or your employer) and the insurance company. Specific questions about eligibility and plan coverage should be directed to your insurance or your employer.
AUTHORIZATION
I have read and fully understand the above information. I understand that I am responsible for (regardless of insurance coverage) any charges incurred from serviced rendered. I agree to be responsible for all charges not paid by my dental plan.