FINANCIAL AGREEMENT
Thank you for choosing us to provide your dental care. We consider it an honor to have been chosen by you to do so. Our philosophy in serving people is to be informative, honest, and forthright. Nowhere is that more important than in the area of finances. This Financial Agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances. If you have any questions or concerns about our Financial Agreement please do not hesitate to ask our business office staff.
DENTAL INSURANCE As a courtesy we will gladly file your claims and accept assignment of dental insurance benefits provided you agree to the following:
• You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim.
• Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you and not your insurance company.
• You are responsible for our fees and not what your insurance company allows or consider "usual, customary and reasonable" all of which vary from one company to another.
• Although we may estimate your insurance benefits we are not responsible for their accuracy. Knowledge of benefits as well as benefit amounts, limitations, exclusions, waiting periods, etc. is entirely YOUR responsibility. Receiving our services indicates your acceptance of responsibility to pay regardless of our estimate.
• All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. Not all the services we provide are covered benefits. Benefits differ from one company to another. Fees for non-covered services, along with deductibles and co-payments are due at the time of treatment.
• Patients with Delta Dental Insurance will pay in full at the time of service & as a courtesy a claim will be filed on your behalf. Any Insurance Reimbursement will be issued to the Subscriber
PAYMENT POLICY
• We accept cash, personal checks, debit cards, Visa, MasterCard, American Express, and Discover. For those who qualify, we also accept Care Credit. Care Credit offers no interest financing for up to twelve months. If you choose to pay cash in full, before the treatment day we will gladly extend a 5% cash savings.
• After dental insurance has paid its portion, a statement is sent to the mailing address on record, for the remaining balance.
• We do not file claims for medical insurance or more than one dental insurance company per patient.
PATIENTS WITHOUT INSURANCE COVERAGE
We provide written estimate of fees, and payment is expected at each visit for services rendered.
MINOR PATIENTS
The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit.
RETURNED CHECKS
A $25.00 charge applies when a check is returned by the bank.
We understand temporary financial problems may affect timely payment of your balance. In those situations, we encourage you to communicate any such problems immediately so we may assist you in the management of your account.
FINANCIAL AGREEMENT CONTINUED OVERDUE BALANCE
An account with an unpaid balance past 90 days will be sent to the collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt: an interest rate of 21% on the unpaid balance from the last date of service, attorney fees, court fees and any other fees associated with the collection of your debt.