Financial Policy Statement

Please correct the errors described below.

Payment for services, including deductibles and copayments, are due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or credit cards. Any arrangements for third-party financing (such as Care Credit) must be made before starting treatment.

We do not offer payment plans, but when a procedure takes multiple visits we will divide your total payment across the number of visits. We will accept Care Credit for procedures above $500.00 – please apply for this on the Care Credit website prior to the start of treatment.

Dental Coverage: We are happy to submit claims to all traditional and PPO style dental plans. (We do not work with HMOs – please pay in full, and we will provide a detailed receipt). We generally submit claims on the date service is rendered – please make sure you have provided us with the most up-to date information. When applicable, copays are due at time of service.

The insurance contract is an agreement between you and the insurance company. You are responsible for understanding your plan’s covered services and payment policies as you are ultimately responsible for all charges. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed.

Denied claims: if a claim is rejected/denied due to billing errors or missing information we will automatically resubmit your claim. If your claim is denied per plan policy the unpaid balance is your responsibility and you should follow your plan’s grievance procedure.

To maximize your benefits, and because plans differ from carrier to carrier and from policy to policy, we advise that you contact your carrier or your employer’s benefits coordinator for assistance in understanding your plan. Please note that dental insurance is intended to cover some but not all dental care costs, and not all services are covered by your plan.

Statements

If you have a balance due after we have received payment/response from your insurance plan we will mail you a statement. The statement balance is due upon receipt. It may be paid by mail (check) or on our website: levasseurdental.com using credit, debit, or e-check. Unpaid balances are subject to late fees and interest charges.

Fees

  • Returned check/insufficient funds: $15
  • Late Fee/Multiple requests for payment: $5 for each additional statement sent on outstanding balance
  • 2% interest/month on balances outstanding 120 days

Please indicate your understanding and acceptance of these financial policies by signing below.

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.

© ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association.

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