If you
have dental insurance:
As a courtesy, we will file your claim for you. We may accept direct payment
from most insurance companies. We will estimate your deductible and the portion
not covered by your insurance, which is due at the time of treatment.
Our estimates may be different than your insurance company's calculations;
therefore, the amount due our office may be adjusted accordingly. You may find
that our fees may be different from the insurance company's schedule of
"allowable" or "UCR" fees. If you have questions about "UCR" fees, please feel
free to ask. All services rendered are charged directly to the patient, and the
patient is ultimately responsible for the account regardless of insurance
coverage. Any insurance claims denied or remaining unpaid after 30 days will
automatically become the responsibility of the patient.
Financial Arrangements
All patients, please read the following…
Payment for services is expected at the time service is provided. If
treatment
requires multiple appointments, payment may be divided over the number of
appointments. Cash and personal checks are accepted. MasterCard and VISA
credit card payment are also welcome. If an extended payment plan is
desired, please ask us about the Dental Fee Plan program. If you have any
questions, please feel free to ask.
"I understand and
agree that all services rendered me, my dependents, or others
assigned by me to my account are charged directly to me. I further
understand I am personally responsible for payment. If I suspend or
terminate care and treatment, any fees for services rendered will be
immediately due and payable. Should the fees for the professional services
not be paid in accordance with the provisions herein, reasonable attorney's
fees, plus applicable finance charges and disbursements, allowances and
costs provided by law shall be included in the computation of the amount
due. Finance charges can be applied to all past due amounts at the rate of
1.5% per month (18% annual rate). If the account is in default and turned
over for collection, a collection fee will be added."
