This is an agreement between Drake Dental, as creditor and the Patient/Debtor named on this form. By executing this agreement, you are agreeing to pay for all services that are received. Payment in full for your portion is expected at the time of service or a $25 handling fee will be added. All insurance co-payments and deductibles are expected at the time of service.
We gladly accept cash, Visa/Mastercard, or check (for existing patients with established payment history). There is a $35 fee for any returned checks returned from the bank.
For treatment involving laboratory fees (crowns, bridges, dentures, implants, etc.) you may choose to pay 50% when you scheduled the appointment and 50% at your actual appointment.
If you are in need of extended financing, we are pleased to offer a third party financing option through Care Credit, for those who qualify.
Insurance: Your dental benefits (insurance) are based upon a contract made between your employer and an insurance company. We are not a party to this contract in most cases. As a courtesy, we bill your insurance company. We currently accept all private care insurance plans. This means that we work with literally hundreds of companies. Although we can maintain computerized history of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like a more accurate insurance benefit estimate, we will be happy to file a "pre-treatment authorization" with your insurance company prior to treatment. This does delay treatment but will give you a better estimate of the out of pocket figure you may require. Please be aware that this is still not a guarantee of payment from your insurance. If your insurance does not pay within 90 days, Drake Dental reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but it is important that you recognize that the insurance benefit you have is a legal contract between YOU and your insurance company. Our office is not and cannot be part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
Finance Charge: A finance charge will be imposed on balances not paid within 30 days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one and one half percent (1.5%) per month or an ANNUAL PERCENTAGE rate of eighteen percent (18%). The finance charge on your account is computed by applying the periodic rate (1%) to the overdue balance of your account. The "overdue balance" of your account is calculated by taking the balance owed thirty (30) days ago, and then subtracting any payments or credits applied to the account during that time. The minimum finance charge is $0.50.
Credit History: You give us permission to check your credit and employment history and to answer questions about your credit experience with us. We have the option to report your account status to any credit reporting agency such as a credit bureau.
Broken Appointment Fee: Patients who do not show up on time for an appointment or cancel with less than 2 business day's notice will be charged a fee. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.