Dear Patient:
Thank You for selecting us as your dental health care provider. The following information describes our Financial Policy. Our primary goal is that you receive the optimal treatments needed to restore and maintain your dental health. In order for us to continue being able to provide these treatments, financial flow is a practical necessity. Therefore, we ask you to review this information and if you have any questions or concerns about our financial policies, please do not hesitate to ask one of our office managers.
Payment for services is due at the time services are rendered. We accept cash, personal checks, and for your convenience Mastercard, Discover, and Visa. We have also arranged an agreement with ChaseHealthAdvance to offer interest free payment plans for those who qualify. We will help you process your insurance claim for your reimbursement as long as we have complete insurance information. It would be time efficient if you bring this information before or at the time of your visit. In special instances, we accept assignment of insurance benefits.
1. We ask that you keep in mind the fact that your insurance policy is a benefit to you and a contract between you, your employer, and the insurance company. Due to the fact that we are not a party to that contract, our financial relationship is and will remain with you, not your insurance company.
2. All charges are your responsibility whether or not your insurance company participates. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
3. Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment.
4. If the insurance company does not pay your balance in full within 30 days, we will ask that you contact the carrier to help speed things up.
5. If the insurance company does not pay in full within 45 days, we will require you to pay the balance due with cash, personal check, Mastercard, Discover, or Visa. We are also able to offer an interest free third party option through Chase Health Advantage (subject to approval).
6. Balances older than 90 days may be subject to additional collection fees and interest charges of 1.42% per month. These added fees will become your responsibility, so all efforts will be made not to reach that 90 day mark. In the unfortunate event of a returned check, an additional fee of $35.00 will be added to the amount of the returned check.
We understand that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems to us so that we can assist you in the management of your account.
Please note that, unless canceled at least 24 hours in advance, you may be charged for missed appointments at the rate of a normal office visit. We respectfully ask you to please call the office as soon as possible if you have to reschedule.
Your signature on this form confirms that you have read and understand these policies.
Again, thank you for choosing our Dental Office as your health care provider. We appreciate your confidence in us and will always respect the opportunity to serve you.
Patient’s Signature: Date: 