Payment:
Payment in full is due at the time services are rendered, unless prior financial arrangements have been made. We accept AMEX, Visa, Mastercard, and Debit. Remote payment is also available.
Estimates:
We will do our best to provide you with an estimate for the cost of any dental procedure. These are merely estimates because it is often impossible to know exactly how much a specific treatment will cost until after it is done. For example, a cavity may appear small on a radiograph but when the decay is removed, it is possible that the required filling is larger than originally anticipated.
Insurance/Government Benefits:
Our office is committed to helping patients maximize their dental insurance and government benefits. However, insurance policies and benefit plans can be complex and vary greatly. Therefore, you are fully responsible for understanding your own insurance and/or benefit plan and its associated coverage limitations. Treatment recommendations are based on your dental needs, irrespective of insurance coverage. Additionally, there may be a variance between the amount covered by your plan and the actual cost of a procedure. If your insurance company/benefits provider fails to pay the claim, or if the plan only covers a portion of your dental expenses, you continue to be responsible for payment of services rendered in full.
As a courtesy, we will gladly send your claim electronically, on your behalf, to your insurance company provided that your company allows electronic submission.
Dependants:
A parent, guardian, or caregiver must accompany all dependants who are unable to consent to treatment to their dental appointments. Every dependant will have a designated responsible party who is responsible for full payment of the services rendered. If the responsible party does not accompany the dependant to the appointment, treatment consents and payment arrangements must be made prior to appointment or non-emergency treatment may be denied.
Missed Appointments:
Once an appointment has been made, a room is reserved specifically for you and the dentist/dental hygienist’s time is set aside. Please be considerate of other patients and our clinic and allow at least two business days to reschedule or cancel an appointment in order to avoid a service fee. Service fees may be applied to patients who miss appointments without adequate notice.
Financial Hardship:
We understand that temporary financial problems may affect timely payment of your balance in some cases. In those situations, we encourage you to communicate any such problems immediately with our Office Manager, who can be reached by calling the office during regular business hours.
Financial Consent and Authorization for Treatment:
The estimate provided prior to dental treatment is not an exact calculation of your actual costs and does not reflect all the terms, conditions, limitations, and exclusions that may apply to your insurance coverage and/or government benefits. We cannot guarantee payment or coverage of your claim. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the services received.
By signing this form, I acknowledge that I understand the following:
- I agree to pay all fees and charges for services rendered at Dentistry on Liverpool for the patient listed below.
- I agree to pay all charges when presented with a statement for the patient listed below, unless prior credit arrangements are agreed upon in writing.
- I understand and agree, regardless of my insurance/government benefits, that I am ultimately responsible for any unpaid balance on the patient’s account.