Financial arrangements and awareness are both necessary and beneficial to maintaining a sound professional relationship. We wish to inform you of our office policy in this regard. Our policies are intended to facilitate excellent service to you while minimizing our administrative costs. Please take a few minutes to familiarize yourself with our guidelines. We encourage your questions and comments.

 

As validated by your signature on the bottom of this form, you understand and agree that at Sue Vetter DDS, PLLC, we provide both services covered by insurance and non-covered services that insurance will not pay for. Even if you have insurance, you may still have to pay some or all of the cost of your treatment. This is because of the copay, coinsurance and deductible of your individual policy.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a part of that contract. We urge you to call your insurer at the number on your insurance card if you do not know what your benefits and responsibilities are.

As a courtesy to you we will help you process all your insurance claims. Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard and Visa. We have several payment options available. If you are concerned about your ability to pay your bill, we are happy to discuss this with you before treatment.

Should a balance accrue on the account a statement will be sent and payment is to be made, in full, by the date on the statement. If payment is not paid within 60 days interest may be applied to the entire account balance. A revised statement with the new account balance, payable immediately, will be sent. 

A returned check fee may also be applied and must be payable from you for each check payment returned to us by your bank.  

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.