Appointment Arrival: Please contact our office if you will not arrive at the scheduled time so we can plan accordingly. Arrivals that are 15 minutes past the scheduled time may result in rescheduling.
Credit Card Service Charge: A 3% service fee applies to payments made by credit card.
Patients Without Dental Insurance Coverage:
- Payment is due at the time services are rendered.
- We offer an in-house Dental Savings Plan that provides a discount. See staff for details.
- We accept all major credit cards, debit cards, cash, checks, mobile pay, Care Credit and money orders.
Patients With Dental Insurance Coverage:
- We will submit your claim to your dental insurance. However, all charges are your responsibility from the date services are rendered. Your insurance carrier is solely responsible for processing the claim and applying your benefits. If you have questions about how a claim is processed, you may discuss this with your insurance carrier.
- Out-of-Network – We accept out-of-network insurance companies (with some limitations). Coverage can vary significantly from plan to plan. Check benefits prior to each appointment to be sure to have the most current information. If you would like assistance with benefits, please provide us with advanced notice.
- Pre-Treatment Estimate – As a courtesy, we provide pre-treatment estimates for services. The purpose of an estimate is to get a general idea of expected coverage and cost before treatment begins. The estimated patient portion is due at the time of service. If no estimate is available, if your insurance company does not provide estimates, or if treatment is urgent, we will contact your insurance to review your current benefits and limitations and base cost on that information. In these cases, the amount collected will be considered a deposit. Please note that estimates are not a guarantee of coverage, and the final insurance coverage and patient cost may differ once the claim has processed.
- Usual and Customary Rate (UCR) - Our fees are based on the usual and customary rates for our area. In some situations, the reimbursement rates used by insurance companies may not reflect actual local fee standards.
Finance Charge: A finance charge may be imposed on balances not paid in full within 60 days of the initial billing statement. The charge is a maximum of 1.5% of the balance due per month, as permitted by Minnesota law. Exceptions may apply in cases involving delays due to insurance or other extenuating circumstances.
Default of Payment (Past Due Balance): In the case of default of payment, the patient or parent/guardian is responsible for any finance charges on the remaining balance, as well as all collection costs, including but not limited to reasonable attorney fees and/or collection agency commissions incurred while attempting to collect the debt. If an account becomes delinquent, appointments may be canceled- those for family members who share the account-until the balance and applicable fees are paid in full.
Appointment Cancellations: We require 24-hour notice for appointment cancellations or rescheduling. A fee will be charged if we do not receive this notice. One late cancellation or reschedule is allowed per 12-month period; additional occurrences may incur fees. Fees are determined based on the type and length of the appointment. Exceptions will be made for illness, weather, or other extenuating circumstances.
Minors: Children under the age of 18 must be accompanied by a parent/guardian to authorize treatment and inform us of any recent health changes or concerns. If a minor will be attending an appointment alone, the parent/guardian must contact our office ahead of time to provide authorization. If authorization is not received in a timely manner, the appointment will need to be rescheduled.
I have read, understand, and agree to the above policies. I accept full responsibility for all fees related to services rendered at at Interlachen Dental Associates.