PATIENT AGREEMENT AND FINANCIAL POLICY
Your dental insurance is designed to assist you, the policy holder, with dental costs. However, few policies provide complete coverage. Payment of our fees are your responsibility and are due in full at the time of service. I hereby agree to be responsible for the costs of care provided by Gatlin Creek Dentistry and/or the dental team for myself or my dependent(s). These include any deductibles and amounts not covered by insurance. I also understand that it is my responsibility to be aware of any limitations, and benefits of my insurance policy. As a courtesy to you, we will file insurance for your dental care, help you maximize your benefits and accept assignment of insurance benefits in place of payment in full, with the following understanding:

• We must be able to verify benefits prior to the procedure.
• Patient agrees to pay any portion of our fees that the insurance company will not cover prior to treatment. This would include deductibles and uncovered procedures.
• We will file your claims providing we have sufficient information for processing.
• Patient agrees to monitor claims filed with the insurance company, by calling and checking the status of claims over 30 days until paid.
• Assignment of benefits is accepted for a period of 90 days from the date our office submits the initial claim to your carrier. Should your insurance company fail to provide benefits within this 90 day period, your remaining balance will become due and payable.

NOTICE
Please inform us of any dental insurance changes. If you do not have a dental card you must provide all your dental information. We will file one time as a courtesy. If we have the wrong information or you request us to re-file any claims there will be a $50.00 fee if you would like our office to re-file.

Insurance carriers have established Usual and Customary Rates. We have contracted with your insurance company in order to see you as a patient and therefore accept the UCR they have set. These fees are often lower than the Gatlin Creek Dentistry fee schedule. In addition, some services that are necessary in reference to diagnosis by the Dr. Whisenant are not always covered by the insurance policy. These services will be explained to you in terms of necessity and cost estimates provided.

I understand that failure to pay amounts due to this office will result in my account being placed with a collection agency. If my account is further referred to an attorney,
I agree to pay all collection and attorney fees.

Please inform us of any dental insurance changes. If you do not have a dental card, you must provide all your dental information. We will file one time as a courtesy.
If we do not have the correct information, any balance becomes the patient’s responsibility.

Insurance carriers have established Usual and Customary Rates. If we are contracted with your insurance carrier we have agreed to accept the UCR they have set.
These fees are often lower than the Gatlin Creek Dentistry fee schedule. In addition, some services that are necessary in reference to diagnosis by Dr. Whisenant
are not always covered by the insurance policy. These services will be explained to you in terms of necessity and cost estimates provided.

MINOR/CHILD:
I understand that the parent or guardian who brings my child in for treatment will be responsible for payment. A receipt will be provided so I may seek reimbursement.

APPOINTMENT POLICY
I understand that because appointments are not double-booked, I must provide notice of cancellation at least 24 hours prior to my scheduled appointment time. For appointments scheduled for 90 minutes or longer, I will be required to make a reservation fee of $100 prior to scheduling the appointment, which will be applied to my out-of-pocket expense for the appointment. This reservation fee is non-refundable. If I do not show up for my appointment or I do not give adequate notice if I am unable to keep my appointment, the reservation fee will be forfeited.

For appointments scheduled for less than 90 minutes, a $50 cancellation fee may apply if I do not provide notice of cancellation at least 24 hours prior to my scheduled appointment time.

We make every effort to schedule appointments that are most convenient for you and that fit your personal schedule. Because we do not schedule several patients at the same time, all appointments are reserved exclusively for you. In return, we ask that you make every effort not to change your reserved dental appointment.