Our goal is to provide the highest quality of care possible and to have clear communication about our policies on financial issues.BASIC POLICY: Patients are required to pay any estimated insurance deductibles, coinsurance, or non-covered services on the day of surgery in full. For uninsured patients, payment is required in full at the first appointment. Our office accepts cash, personal checks, Care Credit, Mastercard, Visa, American Express, and Discover Card.MEDICAL & DENTAL INSURANCE REFERRAL FORMS: I understand that it is my responsibility to obtain any insurance referral form(s) that my insurance company requires for billing from my Primary Care Physician, or my Primary General Dentist listed on my insurance card(s). I understand that if I have not obtained these form(s), I will be responsible for payment of services in full if the insurance company rejects payment on any submitted claim.RETURNED CHECKS: There will be a $35 returned check fee due and payable for each check payment returned to us by our bank. Other applicable fees may apply.BROKEN OR CANCELLED APPOINTMENTS: We reserve adequate time and personnel for a full and thorough appointment, and it is our policy to minimize wait time. In fairness to other patients and staff, we strongly recommend at least 48 hours’ notice when cancelling or changing appointments. The practice reserves the right to dismiss patients with excessive cancelled appointments.LATE ARRIVALS: We strive to see every patient as close to their appointment time as possible. Late arrivals decrease our ability to do this. If you arrive more than 15 minutes late for an appointment, you may be rescheduled in order to meet the needs of those who are on time.PATIENTS WITH INSURANCE: As a courtesy to our patients, we will be glad to help you obtain the appropriate benefit from your insurance carrier, and bill your carrier as a courtesy to you, provided proper information is supplied to us. The patient or guarantor is responsible to understand their insurance benefits and coverage, responsible for all charges not paid by their insurance company, and responsible for resolving any problems with their insurance company. Insurance filed by this office is not a substitute for payment. By signing, you understand and agree that services not paid by the insurance company are to be paid by the patient or responsible party. Sometimes there is COINSURANCE, DEDUCTIBLES OR BALANCES FOR NON-COVERED SERVICES. If your insurance company has not paid your claim within 90 days after submission, you will be required to pay for services rendered and any insurance benefit later received will be credited and you will be refunded. We will be happy to request a pre-estimate of benefits from your dental insurance carrier, if you request us to do so. Routine treatment is generally performed without submitting a request for pre-estimate of benefits.MINOR PATIENTS: The parent or guardian who signs this form as guarantor for a minor pa8ent is responsible for payment for services. If the guarantor does not accompany the minor to an appointment, they must make prior arrangements for payment. Regardless of insurance coverage, patients 18 and older are responsible for payment for services unless a parent or guardian signs this form as guarantor.DIVORCE SITUATIONS: The parent or guardian who signs this form as guarantor is responsible for all charges incurred during treatment. Our office will not become involved in payment disputes between divorced or separated parents.
I have read, understood, and agree to the above financial policies regarding payment for professional services. I understand I am fully responsible for, and agree to prompt payment of, the full amount of fees and expenses regarding my account. I realize my insurance may deny services or not pay as anticipated. I further consent to be contacted by the practice or any agent of the practice, or any collection agency or attorney to whom an unpaid account balance has been assigned, at any address or any phone number provided (whether cell phone or landline) provided to the practice or their agents, including mail, electronic mail, phone, or text message. This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor of the otherwise payable to me.