Important Information For Our Patients Form

Dental Insurance

We will gladly file your dental insurance. To help us in assisting you in determining your maximum benefit, please bring your insurance explanation of benefits booklet and your insurance card to your first visit. Most plans cover only a portion of the dental fee; therefore, as a courtesy to our patients, we will file your primary insurance for you and ask that you pay the non-covered balance at the time of service. If your insurance company has not paid within 60 days, you will be billed for the unpaid balance and payment in full will be expected at this time. We recommend you become directly involved in communication with your insurance company in order to expedite payment.

Payment Options

We accept all major credit cards, cash, money order, personal check, or Cam Credit. Care Credit is a convenient, interest-free payment plan through an outside financial institution.

Appointments

In order to allow the best possible care for our patients, we reserve a specific day and time just for you and make every effort to see you in a timely manner. We appreciate your promptness and your consideration in NOT changing your scheduled time. However, if you need to change your appointment a 24-hour notice is expected. Canceled, broken, or missed appointments without a 24-hour notice will result in a fee added to your account and possible dismissal from our office.

Patient Agreement

• I understand that my insurance company is an agreement between the insurance company and me: therefore, I am ultimately responsible for all fees incurred for my dental treatment regardless of payment or denial of my insurance claims by my insurance company.
• I authorize insurance payment directly to Saluda Smilemakers, Dr. Sam Wheeler.
• I authorize the release of the necessary information to my insurance company to determine liability for payment and to obtain reimbursement for any dental claims.
• If my account is assigned to an attorney or collection agency, I agree to be responsible for any attorney fees, collection fees, and court cost incurred.

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.