The primary goal of our dental practice is to provide the highest quality oral health care in the most gentle, efficient and enthusiastic
manner. Since our practice is also a business with obligations that must be met, we ask that all patients pay for their treatment in full on
the day of each visit to our office unless prior arrangements have been made.
We accept cash, check, VISA, MasterCard, Discover and Care Credit. Payment of your “estimated” portion is due at the time services are
rendered, such as your annual deductible and/or percentage of the treatment not covered by insurance. As a courtesy, we will gladly
contact your insurance in order to provide an “estimate” of your patient portion. However, despite this, we cannot guarantee the payment
of insurance benefits nor can we provide 100% accuracy of this estimated amount since many factors are involved that determine the
actual payment of benefits once submitted and processed by your insurance. Keep in mind that many insurance companies base their
quoted percentage of coverage (i.e 100%, 80%, 50%, etc.) on their own fee schedule and not our office’s actual fees, which may result in a
balance due higher than expected. Should an outstanding balance due result after your insurance company processes your claim, you will
then be sent a statement.
Outstanding balances on your account are discouraged and must be cleared within 30 days of treatment. Amount due and not paid within
30 days will be charged interest at a rate of 1.5% per month or 18% annually.
Payment Plans are accepted for treatment resulting in a higher balance for existing patients. Usually, we ask that you pay half down and
then make monthly payments from there. If you are unable to make the agreed upon monthly payment, we ask that you make a payment.
Letters will be sent out for late payments. If there is no payment for two consecutive months the account will be referred to Collections.
Delinquent Balances over 90 days old will be referred to Collections. All referred accounts are marked “inactive”. In order to have your
account “reactivated” and continue to receive dental treatment in our office, the delinquent balance must be paid in full. Only after the
total account balance has been paid in full can appointments be made and your account and patient status be reactivated.
A returned check fee of $30.00 (subject to change as bank fees increase) will be added to your account for any returned check. Before we
accept another payment by check, the $30.00 fee plus full payment for the check that did not clear must be paid in cash, VISA, MasterCard,
Discover or Care Credit.
If an overpayment on your account occurs after insurance claims are processed, you may request a refund of the overpayment paid by
you. All patient overpayments will be processed within 30 days of your request and after account reconciliation has occurred.
Your Dental appointments are scheduled carefully. Time, trained personnel and dental equipment are reserved for each procedure.
Missed appointments add to the cost of dental care when reserved facilities are left waiting empty. We request 24 hours advance notice
for rescheduling your appointment. Your account will be charged $20.00 for repeatedly missed appointments without proper notification.
Signature: I understand and accept the financial and the dental insurance policies listed above and have had any and all questions
answered to my satisfaction. I agree to pay for all treatment in a timely fashion as described so as to avoid additional fees. I hereby
authorize my insurance benefits to be paid directly to McCoy Samples Mattingly Dental Clinic. I realize that I am responsible to pay for any
deductible amount(s), my co-insurance portion and for any non-covered services. I understand that I am financially responsible for any and
all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also,
hereby, authorize the release of pertinent medical/dental information to the insurance.
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.