Financial Policy

This form explains our financial policies, including but not limited to, payment expectations, insurance billing, estimates, and patient responsibility for fees. Please review the information below carefully, as it outlines your obligations for payment and important details regarding insurance and treatment costs.

As validated by my signature on the bottom of this form, I understand and agree that:

 

All patient balances are due immediately after treatment is rendered. Please ask us if you are interested in learning about third party financing, which may allow you to finance your treatment in low monthly payments.

Should a balance accrue on the account a statement will be sent and payment is to be made, in full, by the date on the statement. If payment is not paid within 30 days interest may be applied to the entire account balance. A revised statement with the new account balance, payable immediately, will be sent.

 

Unpaid Balances over 90 days old will be subject to a monthly interest of 1.0% (APR 12%). If payment is delinquent, the patient will be responsible for payment of collection, attorneys fees, and court costs associated with the recovery of the monies due on the account.

I understand by signing the document below, If my account becomes delinquent (defined as unpaid for more than 90 days) and is referred to a collection agency or attorney, I agree to pay reasonable collection costs, including collection fees up to 30% of the outstanding balance, and any court costs and attorney’s fees as allowed by law. Once an account has been referred to a collection agency or attorney, all non-emergency future appointments may be cancelled and the patient may not be rescheduled until the account is brought current.

A returned check fee may also be applied and must be payable from you for each check payment returned to us by your bank.

Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by the dentist, not an obligation. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider. If the insurance subscriber is someone other than the patient, the insurance subscriber agrees to be financially responsible for all charges incurred on the account, including any balances not paid by insurance.

If there is dental insurance on the account, I understand that the clinic has established the patient balance based on the information I have provided. Final treatment payment is subject to the terms and conditions of my insurance provider on the date of service. As such, until payment is received from my insurance provider, no patient payment is final.

Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total.

Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental clinics.

A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment.

As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The clinic will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible.

The clinic will make reasonable efforts to accommodate scheduling requests within normal operating hours and based on appointment availability.