Office Financial Policy

Thank you for choosing CLASSIC SMILES, LLC for all of your dental needs. We are committed to providing you with excellent service and convenient financial arrangements.

PAYMENT

Payment is due at the time of service unless prior arrangements have been made with our office. Please ask about our payment options. We accept Visa, MasterCard, Discover, American Express and Care credit.

*WE DO NOT ACCEPT PERSONAL CHECKS*

INSURANCE

Our office is committed to helping our patients maximize their insurance benefits, but as you may be aware, dental insurance is extremely complex. We are always available to answer your questions; however, your insurance policy is an agreement between you and your employer/insurance carrier and as the dentist, we are not party to that agreement. Your patient portion must be paid before or at the time of service. We ask our patients, to provide us with their complete dental insurance information. If the information provided is incorrect; you will be responsible for payment in full immediately and submission of claims for any treatment rendered. As a service to our patients, we will process all primary insurance claims for services and allow them 30 days to render payment in full. After 45 days, the patient is responsible for the entire balance and it will be due in full. The qualities of insurance policies vary greatly; therefore we can only estimate your coverage in good faith, but cannot guarantee coverage due to complexities of insurance contracts.

*We are not responsible for keeping track of remaining yearly dental benefits*

MINORS

Payments for services for the treatment of minors is the responsibility of the adult accompanying the minor.

MISSED APPOINTMENTS

Once an appointment has been made, please remember that this time has been specifically reserved for you. We will make every effort to remind you of your appointment but, ultimately, your appointments are your responsibility. We reserve the right to charge a $75.00/hour fee for any appointment missed or cancelled within a 48-hour period of the appointment time.

SERVICE CHARGES

We will charge a 1.5% monthly (18% annual percentage rate) or billing charge which will be applied to all accounts over 60 days past due. For all Ach Debits that are made over the phone and rejected we will charge a $25.00 service fee. Any fees incurred to collect payments from a patient through a professional agency will be billed to and payable by the patient or the patient’s responsible party.

FINANCIAL CONSENT

The patient or responsible party agrees to be fully responsible for the total treatment performed in this office.

I fully understand and agree to the terms of this financial policy

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.