We at Modern Endodontics are prepared to assist you with the various methods of payment available for your endodontic procedure. For your convenience, we accept cash, Visa, MasterCard, Discover and American Express. We also participate with Care Credit, an outside healthcare financing program that offers deferredinterest payment plans upon approval. Unfortunately we no longer accept personal checks but we will take a bank check.

The primary goal of our endodontic practice is to provide the highest quality oral health care in the most gentle, efficient and compassionate manner. Since our practice is also a business with obligations that must be met, we ask that all patients pay their portion in full on the initial day of visit unless prior arrangements have been made with the office manager.

We will do our best to provide you with a rough estimate of your investment in your dental health based on your individual treatment plan. With a proper diagnosis and timely treatment, most estimates we provide are accurate.

Outstanding balances on your account must be cleared before the next appointment or within 30 days, whichever comes first. Appointments for non-emergency treatment may need to be postponed pending payment of outstanding balances. Amounts due and not paid within 30 days will be subject to a monthly flat fee of $39.00.

Delinquent balances over 90 days old will be referred to Peter Roberts & Associates for collections. Please be aware that any and all collections fees will be transferred to you. All referred accounts are marked “Inactive”. In order to have your account “Reactivated” and continue to receive care in our office, the delinquent balance plus all incurred fees in the collection thereof must be paid in full. Once we have confirmation of payment, accounts will be “Reactivated”.

A returned check fee of $40.00 (subject to change as bank fees increase) will be added to your account for any returned check. Future payments must be made by cash or credit card (please reference above for which cards are accepted).

Dental appointments are scheduled carefully. Time, trained personnel and dental equipment are reserved for each procedure. Missed appointments add to the cost of dental care when reserved facilities are left waiting empty. We request 48 hours advance notice to reschedule your appointment. We reserve the right to charge your account a broken appointment fee of $75.00 for repeatedly missed appointments without proper notification.

Prior to your first appointment, we must have your dental plan information. If your benefits change, it is your responsibility to notify our office as soon as possible.

Although we submit claims for you as a courtesy, your dental policy is a contract between you, your employer and your dental company. Even if we participate with your plan, you are still ultimately responsible for any unpaid balances.

We will always do our best to help you maximize your benefits.

Treatment plans are individually tailored and are not based on your plan benefits or lack of benefits

Not all services are a covered benefit in all contracts. Some dental companies arbitrarily select certain services they will not cover. It is your responsibility to understand the coverage and exceptions of your particular policy. Coverage issues can only be addressed by your employer or group plan administrator. We cannot act as a mediator with the carrier or your employer.

Our team is trained to help you with questions you may have relating to how your claim was filed or regarding any additional information your carrier may need to process your claim. Please feel free to ask if you have any questions

Although we file claims as a courtesy, occasionally certain plans will only issue payment directly to the subscriber of the plan. This may or may not be the patient. In such cases, payment is due on the day of service if we are aware of this clause. Any payments made directly to your household/subscriber by your carrier on unpaid balances should be forwarded immediately to our office so your account may be credited accordingly. Balances over 30 days old will be subject to a monthly flat fee of $39.00.

Claims are filed daily and benefits are expected to be paid within 30 days. The filing of a claim does not relieve you of timely payment on your account. Claims that are not cleared by your carrier in 60 days will result in the unpaid balance becoming “self-pay” and a statement will be issued to you for the unpaid balance. Any balance not paid by your carrier is your responsibility, for whatever reason. Balances over 60 days may be subject to a monthly flat fee of $39.00.

I understand and accept the financial and the dental benefit policies listed above and have had any and all questions answered to my satisfaction. I agree to pay for all treatment in a timely fashion as described so as to avoid any additional fees.

I hereby authorize my dental benefits to be paid directly to Dr. Christopher Mirucki or Modern Endodontics. I realize that I am responsible to pay my deductible, my co-insurance portion and any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said dental plan and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the dental carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.