Financial Agreement

We believe in optimum communication with our patients; therefore we ask that you please read the following information and ask any and all questions so we may help you fully understand our financial and appointment policies.

Before we begin with treatment, we will provide for your review and approval either a verbal or written explanation of the recommended treatment and an estimate of the fees involved. Your acceptance of treatment and financial responsibility is documented prior to treatment.

Upon acceptance of treatment is this office the patient/guardian assumes financial responsibility for payment of fees. Treatment is to be paid in full when services are rendered unless other arrangements have been discussed and finalized. This may be in the form of: Cash, Check, Money Orders, MasterCard, Visa, Discover, American Express, and Care Credit. If a payment by check is dishonored, the account will be assessed a service fee of $35. If you are unable to pay for treatment in full, we have financing options that are available, upon credit approval. We do not offer monthly billing within the office, but we work with outside finance companies that upon credit approval, can give you monthly billing options.

The adult accompanying a minor and the parents/guardians are responsible for full payment. Unless altered by a divorce decree or child support order, ME law provides that both parents are jointly and responsible for treatment provided to their children. Unless you provide us with a valid court order to the contrary, we reserve the right to pursue either or both parents in the event of non-payment for services rendered to a child. For unaccompanied minors, non-emergency treatment will not be performed until financial arrangements have been made.

We appreciate your courtesy of giving us a 24-hour notice if you have a conflict with your appointment and need to schedule on a different day or time. The doctor reserves appointment times exclusively with each patient. We are committed to being here to serve you and ask that you honor your commitment to us as well. We will not charge for your first missed appointment, however, the office reserves the right to charge a missed appointment fee of $50 dollars after two occurrences in a 12-month span of either short notice cancellations (less than 48 hours) or for those who do not show/miss their appointments. Please keep us informed of any changes to your health information as well as your address, phone, email or insurance information so that we may serve you in the best possible manner.

We will provide monthly statements for unpaid balances through ninety (90) days. All accounts unpaid after ninety (90) days will be deemed past due and may be sent to a collection agency. You agree to pay all finance charges (18%) and cost of collections (25%), including reasonable attorney’s fees.

I hereby give my consent to be treated on an ongoing basis by the dentist and other clinical personnel of Roosevelt Dental Care. I understand that I have the right to revoke this consent in writing at any time, except to the extent that a dentist or other clinical provider has taken reliance on my consent previously given. I have read and understand, and I agree to the financial terms and conditions set forth above. I hereby authorize any insurance benefit to be paid directly to Roosevelt Dental Care. I also authorize Roosevelt Dental Care to release any information necessary to process an insurance claim or to otherwise obtain payment for services rendered and disclose any protected health information to necessary healthcare providers (Oral Surgeon, Endodontist, Periodontist, etc.). I have read and understand the above financial policies. For this purpose, a photocopy or online submission of this signature is as valid as an original. I authorize payment of primary insurance benefits directly to the dentist otherwise payable to me.