Financial Policy

The following is a statement of our Financial Policy, HIPPA, Missed Appointment and Signature on File. We require that you read, agree to, and sign prior to any treatment.

PATIENTS WITH INSURANCE COVERAGE: AS A COURTESY TO YOU, WE WILL FILE YOUR SERVICES TO YOUR INSURANCE. WE DO OUR BEST TO UNDERSTAND YOUR DENTAL BENEFITS, HOWEVER THEY ARE YOUR BENEFITS. YOU SHOULD UNDERSTAND YOUR POLICY. WE ARE NOT RESPONSIBLE IF YOUR FREQUENCIES OR COVERAGE CHANGES WITHIN YOUR POLICY.

You are responsible for all charges on your account regardless of your insurance.

• Any treatment plans we render are estimates only and are no guarantee of payment until the actual insurance payment has been made.
• Your co-pay or deductible plus the estimated out of pocket, on the day of treatment. Any procedures that have lab costs will require 50 % down on the day treatment is started.

METHODS OF PAYMENT

If any financial arrangements are provided by the office, there will be a 3-month maximum allowance.
If the account goes 90 days without payment it will be sent to collections or small claims court (with additional filing fees) automatically.

Payment options:

1. Cash / Check
2. Credit Card
3. Care Credit- a special lending institution for dental purposes

PATIENTS WITHOUT INSURANCE COVERAGE

• For our new patients without dental insurance we require $120 on your first appointment. We then can make further arrangements for the remainder of the balance. Not to exceed 90 days
• Any procedures that have lab costs will require 50 % down on the day treatment is started.
• We offer a 5% discount for payment in full at the time of service. For our senior patients the discount is 10%.

FINANCE CHARGE

A finance charge of 19% will be added to all accounts after 90 days. A fee of $25.00 is applied to all checks returned by the bank.

MISSED APPOINTMENTS

• There will be a missed appointment deposit of $25 to all patients that fail to keep their scheduled appointment, or do not cancel within 48 hours in advance. The appointment time is reserved especially for you. This deposit will be applied to your next appointment if rescheduled.

DIVORCE DECREES / MINOR PATIENTS

• This office is not party to your divorce decree. The financial responsibility for children involved rests with the accompanying adult.
• The adult accompanying a minor is responsible for payment at the time of treatment. Unaccompanied minors will be denied non-emergency treatment unless pre-authorized by a parent/guardian. Payment is still expected at the time of service.

HIPAA

I authorize the release of my PHI via electronic transmission and any other patients on my account. I acknowledge the Notice of Privacy Practices is posted and I was offered a copy of their notice.

Please be sure all boxes above are initialed and print and sign below.

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