Thank you for choosing Asheville Smiles Cosmetic & Family Dentistry for your dental needs. We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget.We are committed to providing you with the highest quality of care. Our fees are a reflection of the quality of care we provide.We accept Cash, Check, VISA, Master Card, Discover and American Express. We have also partnered with a third-party, Care Credit and Cherry, to offer the flexibility of deferred interest, extended payment, and monthly payments options. Check policy: If your check is returned for any reason, we will expect payment for the amount of the check plus a processing fee of $75.00. Initial All of our fees or copays are expected at the time treatment is rendered. The parent or guardian who accompanies a child to our office for treatment is responsible for payment of services rendered. Initial Dental insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract. The filing of insurance claims is a courtesy that we extend. It is your responsibility to understand the type of dental insurance you have and the benefits selected by you and/or your employer. Initial Please note: Not all services are a covered benefit in all contracts. Most insurance plans are not designed to pay the entire fee. Your insurance more than likely will not cover 100% of any services. Many policies have deductibles and copayment clauses that limit their liability. Due to the complexity of insurance contracts, we can only estimate in good faith, not guarantee coverage or benefits. Initial Please contact your insurance carrier prior to your visit to obtain essential information which will accurately reflect your coverage. This information, as well as a detailed breakdown of your dental benefits, is also available on the website listed on your insurance card.If your insurance coverage changes, it is also your responsibility to notify our office prior to your visit. Verification of benefits is required. If we are unable to verify your benefits, you will be responsible for payment in full at the time services are rendered. Dental insurance verification can take several hours to obtain. It cannot always be completed upon arrival at your visit and before your service is completed. Providing us with this information will expedite the processing of claims and estimating your portion as accurately as possible. Initial We will accept insurance on assignment, but you must pay your deductible and any patient portions due at time of service. You are required to sign an “Authorization to Pay Dentist/Physician” form and any other assignment documents required by your insurance company on your first visit. If your company requires their form to be filled out, you will need to bring that form with you at each visit. Without the required information completed, we CANNOT file for payment and you will be asked to pay up front for each appointment. Initial Your ESTIMATED portion is also due at the time of your visit. You will be billed if your insurance does not pay the estimated amount. We will make every attempt to help you know your benefits; but, it is ultimately your, the patient’s, responsibility to know them. If you have a direct reimbursement policy, payment in full is expected on the day of service and your dental plan will reimburse you directly. Initial Our office does NOT guarantee that your insurance will pay. If your insurance company fails to pay your claim within 60 days, you may be billed directly for any applicable amounts. Any balance that is not cleared in 90 days may be turned over to collections. Initial Our office will NOT enter into a dispute with your insurance company over a claim. We file insurance as a courtesy. Accounts not paid in full after 90 days from the time services are rendered may be referred to collections or pursued legally in the courts. Initial Late payment fees will be applied on bills that are 60 days past due. We also will not be able to reschedule your appointment if you have a bill outstanding longer than 90 days until the payment is due in full. Initial If you are experiencing financial hardship, please feel free to discuss your situation so arrangements can be made.If you have any questions concerning our office payment policy, please feel free to ask.I understand and agree that I am responsible for the balance on my account for professional services rendered. I understand that any insurance benefit is between my insurance company and me; and that this dental office, Asheville Smiles Cosmetic and Family Dentistry, does all in its power to help obtain those benefits. I have read, understand and agree to the above financial arrangements policy and agree to indemnify Rebekkah Merrell, DMD, MS PLLC, for all expenses that may be incurred in order to enforce collection of any amount due under this agreement. Patient also agrees to pay reasonable attorney’s fees and court cost incurred in such collection. I have read and understand all the above.