Thank you for choosing Sumner Smiles Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of our mission is making the cost of optimal care as easy and manageable as possible. We will provide you with an estimate of the fees expected. Once dental treatment has begun, changes in the anticipated treatment may be required, depending on oral conditions encountered. We will inform you if this occurs and you will be given the option of continuing or changing treatment. If you have any questions about your treatment, please do not hesitate to ask, we are here to help you get the dentistry you want and need.
Please read the following statements. If you have any questions regarding this information, please ask us, we are here to help you.
- Patient portion and/or co-payments for services rendered are due at the time of service, unless prior arrangements have been made. For your convenience, financing may be obtained for full and/or partial treatment through Care Credit, a third party financing company.
- A 1.2% per month (12% annually) finance charge may be added to any account with a past due balance of 90 days starting from the date services are rendered. Or a late payment fee of $25.00 per month.
- We do not accept DSHS, Medicare or Medicaid.
- YOUR APPOINTMENT IS SPECIFICALLY RESERVED FOR YOU. A fee of $100.00 PER HOUR MAY be charged and paid by the patient for any appointment that is missed, rescheduled or cancelled without at least TWO business days’ notice.
- Nitrous oxide is available for $100. PER HOUR. This is not a covered benefit under dental insurance, and payment is due at the time of service.
Insurance
When estimating insurance coverage, we must also stress the word estimate as dental benefits are determined by each patient’s dental contract. Most dental insurance plans are designed to assist patients with their dental expenses; very few dental plans fully cover all dental services. As a courtesy to you, we will file your insurance forms. Insurance coverage, reimbursement, and benefits are a contract between you and your insurance carrier. As a courtesy to you we will bill your insurance; however, this is NOT a guarantee of insurance payment. Payment of your dental services not covered or paid by your insurance is required at the time services are provided. When patients have Dual Insurance coverage, there may be instances where the two insurances will not cover 100% of services. In such cases, patients’ are responsible for any portion not covered by insurance(s).
I have read and understand the above, stated guidelines and services. I understand that I am financially responsible for all charges whether paid by insurance or not. I authorize the doctor to release all information necessary to secure payment of benefits. I authorize and request my insurance company pay directly to the dentist the insurance benefits otherwise payable to me. I authorize the use of my signature below to all insurance submissions. I understand that my dental insurance may pay less than the actual bill of services.