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: There is a 3% service fee applied to payments made by credit card.
Patients Without Dental Insurance Coverage:
- Payment in full is due at the time services are rendered.
- We offer a 5% cash/check discount for self-paying patients. Debit cards do not apply.
- 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 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.
- Estimate of coverage – As a courtesy to our patients, we provide estimates for various services. Your estimated patient portion or deposit is due at the time of service. If an estimate is unavailable, if your insurance company does not provide one, or if an emergency occurs, we will base an estimate on your current benefits and limitations. Please note that estimates are not a guarantee of coverage, and the final amounts owed may differ once insurance has finalized a claim. The purpose of the estimate is to give a general idea of coverage and cost.
- Usual and Customary Rate (UCR) - Our fees are based on the usual and customary rates for our area. In some situations, the rates paid have no bearing on the real “usual and customary rates” charged in local areas.
Finance Charge: A finance charge is imposed on charges not paid in full within 60 days after a billing statement has first been issued. The finance charge will be a maximum of 1.5% of the balance due, per month, under the laws of Minnesota. Exceptions apply for accounts that have had delays due to insurance or other extenuating circumstances.
Default of Payment: In the case of default of payment, the account holder is responsible for finance charges due on the remaining balance and any collection costs, including, but not limited to, reasonable attorney fees and/or commission fees that have incurred while attempting to collect on the debt. If an account has had a default of payment, all appointments associated with that account may be cancelled until the balance and applicable fees are paid in full.
Appointment Cancellations and Failure to Show: We require 24-hour notice for appointment cancellations and reschedules. A fee will be charged if a 24-hour notice is not received. One late cancellation or rescheduled appointment per 12-month period is allowed, all others in the 12-month period that follows will have a fee. Exceptions will apply for illness, weather, or other extenuating circumstances.
Children under the age of 18 must be accompanied by a parent/guardian to authorize treatment. If the child is attending the appointment alone, the parent/guardian must contact our office prior to the appointment to provide authorization and to inform us of any health changes. If a parent/guardian does not attend with a child under the age of 18, the appointment will need to be rescheduled.
I have read, understand, and agree with the above policies and I am fully responsible for the fees for services rendered at Interlachen Dental Associates.