APPOINTMENTS: We require a 24-hour notice when cancelling appointments in order to avoid being charged a broken/cancelled appointment fee. The office incurs expenses, even when you do not come for your scheduled appointment and we find it necessary to charge a fee of $50.00 per half-hour of scheduled time. A courtesy call with a 24-hour advance notice will prevent this.
INSURANCE: Our office is a provider for Delta Dental of Rhode Island and its affiliates, Blue Cross and Blue Shield of Rhode Island and its affiliates, and MetLife. Regardless of what insurance carrier you may have, we will file your claims as a courtesy to you. On the date the services are performed, your estimated portion of payments (co-pays and deductibles) will be collected. We will help with explaining your insurance, but as the patient, you are ultimately responsible for knowledge of your policy; including yearly maximums, co-pays, deductibles and services not covered.
BALANCES: For any delinquent and outstanding balances owed to this office, plus applicable interest, the patient or person(s) responsible for the account will also be responsible for any and all cost to recover said monies. These costs will include, but not be limited to, collection agency fees, court fees, sheriff fees, lost billable hours associated with the doctor’s or employees’ appearance in court and all attorney fees.
I HAVE READ THE ABOVE STATEMENT AND UNDERSTAND IT.