Cash/Credit or Debit Card:
We require all co-pay and deductibles to be paid at time of service. Any payment arrangements need to be made with our office manager.
OAC we offer up to 12 months no interest over a $1000 and six months no interest below $1000 with a minimum of $300.00 plus. Speak to our front office for details.
We are pleased you have dental insurance. However, our primary role is to provide excellent dental care and our relationship is with our patients directly. As a courtesy, we will submit your insurance claim for the care you receive from our practice. Any issue with your insurance company after a claim is submitted that does not meet your expectations will be between you and your insurance company to resolve. We will assist with this process as much as possible. Not all services are covered in all contracts. Some insurance companies arbitrarily select certain services they will not cover. You need to understand the scope and limitations of your insurance policy, and that you are responsible for coverage of any service not covered by your insurance contract.
- At the time you receive our service, you are responsible for all copays, deductibles, and all "estimated" fees for items not covered by your plan.
- You will need to provide accurate insurance and employment information. If inaccurate information delays claims, it can result in additional costs and inconvenience to you.
- If your insurance company does not process our correct claim with 60 days of the date of service, the entire balance may be due to you. You can be reimbursed directly from your insurance company or you will be reimbursed by our office for any overpayments.
In the event, an account is not paid, and we refer the account to collections, you will be responsible for all fees incurred for the collection of your bill, including but not limited to attorney fees, court costs, collection agency fees, and late fees on your unpaid balance. In addition, you will be seen by our office on a "cash only" basis or may be dismissed by our office.
All NSF checks will result in the balance due in full five days with all application bank fees. If not paid within five days, account will be sent to collections.
We required a 24 hour cancellation notice. Any Short Notice Cancellations or Missed Appointments will be charged $50.00. These fees are not billable to insurance and are the responsibility of the patient IMMEDIATELY.
I hereby authorize Dr. Readel & Staff to release any and all information necessary concerning my diagnosis and treatment for the purpose of securing payment from my insurance company: and thereby authorize payment of the insurance benefits directly to Dr Readel for any service rendered that are not paid for directly by myself.
Patient Release of Records: I hereby give permission to Dr. Readel & Staff to release my dental record, including current x-rays, periodontal charting, and any other pertinent information to another dental/medical office.
I have read and understand the above information
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.