Financial Policy of Advanced Endodontics, LLC

On or before your initial visit we will make every attempt to inform you what your out-of-pocket expense will be. "It is our policy to receive your portion of the total cost of treatment at your initial visit. We accept cash, checks, debit or credit cards. We do not accept personal checks. If you have any questions about anything on this form, please do not hesitate to ask us."

To our patients with dental insurance:

Please understand that your policy is a contract between you and your insurance company and we are not party to that contract. Most insurance plans do not cover root canal procedures in full. They typically pay a certain dollar amount or percentage of the total charges according to the terms of your policy, and the balance is for you to pay."

Your insurance claim will be filed by this office as a courtesy to you. All co-pays, deductibles, co-insurance, previous balances, and fees for non-covered services are due at the time of your visit. Regardless of what your insurance pays, the balance on the account is your responsibility.

If you have secondary insurance: Once your copay and primary insurance payment are paid in full, we will be happy to file a claim with your secondary insurance. Should the amount paid by your secondary insurance exceed the procedure fee - you will be refunded the difference.

We certainly do our best to estimate your portion based on the benefit information given to us by your insurance company. However, we cannot guarantee the portion quoted to you will fulfill your financial obligation.

When this happens, either you will have a balance after your insurance pays (that you might not have expected), or you will have a credit due. If it is the former, we will send out a bill, and if it is the latter, we will send you a refund check. To best understand your benefits it is helpful to check the explanation of benefits that your insurance carrier provides.

A $25.00 fee will be charged for any appointments not canceled 24 hours in advance or if you do not show up for your scheduled visit. This fee is not covered by your insurance.

Authorization (for all patients)

By signing below, I confirm that the information I provided on the Advanced Endodontics forms is accurate to the best of my knowledge. I have reviewed and fully understand the financial policy of Advanced Endodontics, LLC. I understand that if it becomes necessary to refer my account to a collection agency, which may adversely affect my credit rating, I will be responsible for all related fees. If a balance remains on my account for more than 30 days, I understand I am responsible for a monthly interest charge of 1 ½ % (or 18% APR) with a minimum of 50 cents. I authorize the insurance company indicated on my forms to pay the endodontist all insurance benefits otherwise payable to me for the services rendered. I authorize the use of this signature on all insurance submissions. I authorize this office to release all information necessary to secure payments for services rendered.

For our patients without dental insurance – Please read the following statement and sign:

I understand that I am financially responsible for all charges on my account.

I understand that, regardless of what my insurance carrier pays, I am financially responsible for all" charges on my account.

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.