We are honored you have chosen us for our dental care. In order to keep a completely professional and up front business relationship with our patients, we ask that you read and state that you understand our payment policy and our insurance policy. If you do not have dental issuance please skip down to the bottom of the page.
Payment Options
1. Cash- Includes money orders and personal checks. If the total fee for your services is $500 or more we offer a 5% discount if you pay in full on the originating date of service.
2. Visa/MasterCard/Discover
3. Care Credit — the monthly payment plan is offered as a separate line of credit to cover your healthcare needs. With Care Credit:
- Approval only takes a few minutes
- We offer No Interest Option
- We also offer low interest extended payment plan options, for more time to pay off larger balances.
I understand that my insurance policy is a contract between my insurance company and myself. The contract is not between Gartner Periodontal Care and my insurance company. I know that I am fully responsible for all charges resulting from services rendered to me, including the balance remaining after payment of possible insurance benefits.
In instances where pre-determinations are approved, you may pay your co-payment and we will file for the remaining balance. However, if payment from your insurance company is not received within 30 days we will notify you of the balance due and your payment is expected in full at that time.
If no previous arrangements have been made, all balances overdue by 60 days will have a 1.50% assessed with a minimum charge of $2.00.
We will bill your insurance for you as courtesy, but please understand that your insurance contract will always use an “allowable amount” payment for each procedure provided. This “allowable” is determined by the limitations of the contract that your employer or the individual has purchased from the company and does not always equal the doctor's submitted fee. You will be responsible to the doctor for payment of your yearly deductible, the patient portion and any other remaining portion for the doctor's bill that is not covered by your insurance; we will collect this at the time of service. Any unpaid balance by the insurance company is your responsibility.
I understand that should my account become delinquent, I will be legally responsible for all cost involved with the collection of this account including all court cost, reasonable attorney fees and all other related costs.
Please understand that there might be a fee for any appointments cancelled without a twenty four hour notice.
Please sign and date that you understand and agree to our policy. Thank you.