FINANCIAL RESPONSIBILITY FORM
Dental insurance is unlike medical insurance; it is better described as a “benefit plan.” Most plans have a total allowed amount per year and are specific in what services are covered. Our goal is to work with you to optimize your dental benefits to minimize your out of pocket costs. We will accept assignments of benefits by the insurance carriers we participate with for covered services. Deductibles and co-pays as well as fees for any non-covered services law you will be charged the full fee for service for any services your insurance company deems not covered.
Billing your dental insurance. As a courtesy to you, we will gladly file an insurance claim for services rendered by our providers. In order for our office to file your claim, it is vital that you provide us with correct and up to date insurance information. If any information changes, it is the patient's responsibility to update our office immediately.
Co-pay is due at the time of service. We will fully comply with the regulations and requests of your insurance company to assist in your claim being paid. Once insurance has paid their portion, a statement will be sent to you for the remaining balance and will be due upon receipt. Any unpaid balances are subject to finance charges of 1.5% monthly or 18% annually and the collection process.
Patients who do not have dental insurance MUST pay at time of service. We accept cash, checks, and most major credit cards. Returned checks are subject to an additional $50.00 fee. We also participate with Care Credit. This program offers a line of credit to cover you or your family’s dental care needs. Please speak with one of the office staff to obtain further information regarding the different programs they offer. If you decide to use this program, we will need authorization from Care Credit before your procedure can be scheduled.
Cancellation and No- Show Policy: If you cannot make your appointment, please contact the office immediately. For cancellation less than 48 hours from the time of appointment, we reserve the right to assess a cancellation fee. If you do not show for your appointment and do not contact the office, a No- show fee will be assessed to your account. Consistent no shows may be grounds for dismissal from the Practice.
Records Policy: Our practice complies with the HIPAA guidelines in regards to fees associated with records copying. As courtesy to you, any medical record requests that are less than 10 pages will be provided free of charge. For records requests longer than 10 pages, there will be a fee of $0.25 per page.
I have read and acknowledge the Financial Responsibility Form in its entirety and agree to the terms and conditions herein. I understand and agree that, regardless of my insurance (if applicable); I am ultimately responsible for the balance on my account for all charges and services rendered.