I certify that I (or my Dependent) have insurance coverage as indicated and assign directly to Advanced Dental Care of Twin Falls all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

I certify that the information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or Patient’s) health. I will not hold my Dentist or any of his team members responsible for errors or omissions that I have made in the completion of this form. It is My Responsibility to notify my Dentist of any changes in my medical status.

We, the staff of Advanced Dental Care of Twin Falls, thank you for choosing us as your dental provider. We consider it a privilege to serve your needs and we look forward to doing so. We are committed to providing you with the highest quality care and building a successful provider-patient relationship with you and your family. We believe your understanding of our patients’ financial responsibility is vital to that provider-patient relationship. If at any time you have any questions or
concerns regarding our fees, policies, or responsibilities; please feel free to contact us at (208)734-8080.

Our fees are based on the quality materials we use and the time, effort and skill required in performing your needed treatment. We strive to keep our prices low for our area.

Payment for services is due at the time of service.

We accept the following forms of payment: Cash, Check, and All major credit cards. We offer a 5% cash discount when paid in full at time of service. This discount is reserved for patients without insurance benefits and cannot be combined with any other offer.

Other Payment Options We offer easy-to-budget monthly payments thru Care Credit (third party financing.) They offer a variety of INTEREST FREE options in 6, 12, 18 and 24 month plans.

INSURANCE

Your estimated co-payment will be due at the time of service. We are happy to submit the claims necessary to help you receive the full benefits of your coverage; however, we cannot guarantee any estimated coverage. Please know that we will do everything possible to see that you receive the full benefits of your policy by electronically filing your claim the day of your appointment. If there are any
complications, we will assist you with any information you may need. We allow insurance 45 days to make payment at which time the balance becomes your responsibility.

Unpaid Accounts

Any account balances left unpaid past 90 days of treatment date, will be sent to a Collections Agency. The agency will add approximately 50% to the balance. Patient will be responsible for all fees associated with this process.

We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Most often, financial misunderstandings can be managed with a phone call. Please feel free to contact our wonderful staff to discuss any concerns you may have. Thank you for understanding our Financial Policy.

I have read and agree to the Financial Policy of Advanced Dental Care of Twin Falls

I have received and reviewed a copy of this office’s Authorization for Release,
HIPAA Consent, and Notice of Privacy Practices.

I understand that I should ask our dental practice’s Privacy Official if I have any
questions about these policies and procedures.