Financial Agreement

Please correct the errors described below.

Thank you for choosing us as your dental care provider. Our office is dedicated to providing the best dental care possible to both children and adult patients in the most pleasant and stress-free environment. Please review a brief explanation of our policies and procedures. If you have any questions ask one of our staff to assist you. After you have read this document please sign on the line indicated. Your signature constitutes an agreement to the policies and procedures of our practice.

INSURANCE

IN NETWORK: We refer to "in Network" as the insurance companies with whom we have a contractual agreement. If we are in network, we have agreed upon a pay scale with the insurance company. In other words, we have agreed to a discounted rate for members of the insurance carrier with whom we are contracted. We are contracted with Cigna, Guardian and Delta Denial.

OUT OF NETWORKINON PARTICIPATING INSURANCE: Our office works with most dental insurances. As a courtesy our office accepts assignments of your primary insurance benefits so that you will not be out of pocket for the full amount of service. Our office will estimate your primary insurance benefits for each visit. We can generally estimate your benefits with reasonable accuracy; however, you will be held fully responsible for any amount not paid by insurance regardless of the reason they refuse payment. Insurance often does not pay as much as expected or may refuse payment for certain procedures based on your policy provisions. Waiting periods and other clauses/exclusions will also affect your coverage. Please note your insurance policy is an agreement between yourself, your employer and the insurance company. Please know that we will do everything possible to see that you receive the full benefits of your primary policy. Your estimated portion is due and payable in full at the time of your visit. Assignment of benefits for secondary/supplemental insurance coverage and secondary benefits will be considered at our discretion. If for any reason your insurance company has not paid their portion within 60 days of your date of service, you may be asked to pay the balance in full at that time.

ACCEPT ASSIGNMENT DEFINITION: Accept assignment means that we agree to accept check payments from the insurance company for service rendered.

PAYMENT

AT TIME OF SERVICE: As a courtesy, our office extends the following discounts to our patients that qualify. For our patients 65 and older we extend a 5% Senior Citizens discount on all services paid in full at time of service. Our office also extends a 5% "in full- discount when services exceed $500 in one visit and the total of those services is paid in full at the time of service. Only one discount may be applied per person per visit. A 5% courtesy discount is also extended to patients who follow up recommended exam, x-rays & cleanings on a regular scheduled basis. ·Cash discounts will not be extended to patients utilizing our assignment of benefits on their insurance or patient financing.

OPTIONS: If you require financial assistance in planning for your portion of the bill, please make arrangements with our office prior to your scheduled treatment date. We realize that every person's financial situation is different. For this reason we have worked hard to provide a variety of payment options to help you receive the dental care you need and want with respect to your budget. Our office accepts Checks, Cash, MasterCard, Visa, Discover, CareCredit and CitiHealth Card. CareCredit and CitiHealth offer low or no interest monthly payments plans. Please let us know if you are interested in more information about these services.

There will be a $25.00 fee for all returned checks.

APPOINTMENTS

ACCOUNT UPDATE: In order for our office to properly manage your dental care needs current information is imperative. Please help our office keep your records up to date by informing of any changes to your account. This would include but not be limited to: name, address, phone numbers, email address, employer, insurance and all medical/health history.

CANCELLATIONS/RESCHEDULES: We understand that an emergency may arise and you miss an appointment without notice. Our office reserves the right to charge a $35.00 per hour broken appointment fee. A broken appointment is one that is no showed or cancelled/rescheduled without 24 hours notice. Please remember scheduled appointments are time reserved especially for you. Your 24-hour notice allows us to offer your time to other patients awaiting treatment. If you are unable to keep a scheduled appointment for any reason, please give our office a 24 to 48 HOUR NOTICE during our office hours, Monday through Thursday 8:00 am to 5:00 pm. We ask that you please make every attempt to keep your scheduled appointment.

I have read the above conditions and have had an opportunity to have my questions answered. I understand that by signing this document, I have received, read and understand the financial policy for the office of Michael A. Karleskint. D.D.S., F.A.G.D.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

We would be happy to provide you with a copy of this financial agreement for your records, upon request.

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