Thank you for choosing our office as your dental health care provider. Our primary responsibility is providing the highest quality dental care for you and your dependents. Part of our commitment is your understanding and responsibility for the payment of your accoutn balance.
Our basic finalcial policy is the following:
FULL PAYMENT IS DUE AT THE TIME OF SERVICE. PAYMENT ARRANGEMENTS CAN BE MADE IF EXTENSIVE TREATMENT IS PLANNED AND APPROVED BY OUR OFFICE MANAGER.
WE ACCEPT CASH, CHECK, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, AND CARE CREDIT.
ADULT PATIENT:
Adult patients are responsible for full payment at the time of service unless specific arragements are made prior to the start of treatment.
MINOR PATIENTS:
The adult accoumpanying a minor and the parents/guardians are responsible for full payment at the time of service. For unaccompenied minors, non-emergency treatment will be denied unless charges have been pre-authorized to the credit card or by cash; check at the time of service has been verified.
REGARDING INSURANCE
We accept most insurance companies. Full payment is required at the time of service, we will accept assignment of participating insurance plans and will submit dental claims on our patient's behalf, and we will submit a refun for payment from an insurance company back to our patients in a timely fashion. WE are not able to pre-determine or bill for insurance benefits only. A pre-treatment estimate will need to be submitted to your insurance company to determine the schedule of benefits for any MAJOR service to be rendered. If you have two dental carriers, we will file the primary and the secondary, but it will be your responsibility to follow up with any secondary claims.
YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY; WE ARE NOT A PARTY TO THAT CONTRACT. ANY INSURANCE CLAIM NOT SETTLED WITHIN 60 DAYS WILL BE DUE IN FULL. IT'S YOUR RESPONSIBILITY TO PAY OUR PRACTICE IN FULL FOR THE TREATMENT INVOICE.
Please be aware that some and perhaps all of the services provided may be non-covered services. You are responsible for the entire balance no matter what the outcome is with your insurance. Will will help you as much as possible with your insurance; however, you are responsible to keep track of the amount of benefits you have left throughout the year. If services are rendered and benefits are denied, you are responsible for full payment.
USUAL AND CUSTOMARY RATES:
Our practice is committed to providing the best treatment for our patients and we charge what is usual and sutomary for the quality of the treatment that is rendered. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and sutomary rates. We will do all that is reasonable and proper to have you receive the maximum insurance benefits you are entitled too.
PATIENT RESPONSIBILITY AND ADDITIONAL TERMS:
Accounts unpaid after 60 days from the days service are subject to a deliquent fee of $35.00. Furthermore the unpaid balance is subject to a 1.5% monthly (18% Annual) finance charge. If we have to submit your unpaid account to a collections process, you will be responsible for all charges our practice incurs: including collection fees, court costs and reasonable attorney's fees.
MISSED OR LATE APPOINTMENTS/RETURNED CHECKS:
Unless appointments are cancelled with 24 hours in advance, our policy is to charge for missed appointments. You will be charged a $75.00 non-refundable fee. Any returned checks will carry a $35.00 fee.
EMERGENCY VISITS:
All emergency dental services or any dental services performed without previous financial arrangements must be paid for in full at the time services are performed unless other arrangements are made.
Our entire staff is dedicated to you, the patient. Please let us know if you have any questions or concerns.
I have read this Financial Policy. I understand and agree to the terms of the Financial Policy of Dr. Paul Eliazo. Picture ID is also required with your signature.