Thank you for choosing Dentistry on Liverpool as your dental health care provider. The following is a statement of our Financial Policies which we require our patients to carefully read and sign prior to any treatment. We would be happy to answer any questions you may have before signing.
GENERAL
As a condition of receiving treatment in our clinic, payment is required at the time of service unless previous financial arrangements have been made.
Please understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes but is not limited to: dental fees, co-payments surgical procedures, tests, office procedures and any other services provided by our auxiliary staff.
INSURANCE
Please remember your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Pre-determinations sent to your insurance provider are estimates only and do not constitute a guarantee of coverage or relieve you of your obligation to satisfy your bill with us in full. It is not possible for us to have knowledge and keep track of your insurance coverage, especially when you may receive services elsewhere. In order for you to be fully aware of the benefits which your particular policy provides, you are encouraged to contact your insurance carrier and/or familiarize yourself with the limits and provisions of your policy. Please be aware some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance company pays any portion.
PAYMENT
Full payment for services is due at the time services are rendered unless prior, written arrangements have been made.
The parent (or guardian) that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with our administrative staff.
MISSED APPOINTMENTS
Your reserved time in our office is important. We are committed to being here to serve you and ask that you honor your commitment to us as well. The office reserves the right to charge a missed appointment fee for short notice cancellations (less than 48 hours notice).
I have read the Financial Policy above. I understand and agree to abide by the terms of this policy.