Financial Policy
Thank you for choosing us as your dental care provider. We believe that all patients deserve a beautiful, healthy smile with the best care and education available.
Your clear understanding of our Financial Policy is important to our relationship. The following is a statement of this policy, which you must read, agree to, and sign prior to any services performed.
PROVIDE ACCURATE INFORMATION:
As our patient, you have the responsibility to provide accurate and complete information. The office will need your photo ID, current mailing address, dental insurance card/information [if applicable], and any other information needed for billing purposes. If any information changes (name, address, phone, insurance coverage etc.) you must inform us immediately. Insurance denials and/or billing errors due to incorrect patient supplied information will result in the balance being the patient’s financial responsibility.
KNOW YOUR INSURANCE COVERAGE AND BENEFITS:
Your dental insurance coverage is a contract between you and your dental insurance carrier. You are responsible for understanding your dental insurance coverage including maximums, deductibles, and frequencies. There may be limitations and exclusions to your coverage. Deposits determined by the office are due at the time of service. In most cases, our team will handle submitting your dental insurance claims on your behalf. Please be aware some or perhaps all of the services provided may or may not be covered by your insurance policy. The office cannot guarantee your insurance benefits or coverage.
For patients with out-of-network insurance plans, payment in full is required at time of service, if you have out-of-network coverage you may be reimbursed directly from your insurance carrier based on your out-of-network benefits.
SELF-PAY PATIENTS:
Self pay accounts are patients without insurance coverage or who are unable to provide us with valid insurance. You are responsible for paying 100% of charges at the time services are rendered.
Understand that regardless of insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered.
REGARDING APPOINTMENTS:
Your reserved time in our office is important, therefore all appointments must be confirmed and necessary paperwork must be completed in order to keep your appointment. Please be advised the office requires a minimum of 2 business days’ notice to change an appointment. The office reserves the right to remove appointments due to not following this policy. Any appointment canceled without the required notice, as well as no-shows or broken appointments, will be subject to a cancellation fee of $79 per scheduled hour. It is at the office’s discretion to reschedule late arrivals. Three cancellations within a calendar year will result in same-day only scheduling. More than one no show/broken appointment and or repeat late cancellations may result in dismissal from the practice. Please help us maintain the highest quality of care by keeping scheduled appointments.
OUTSTANDING BALANCES AND COLLECTIONS:
All overdue balances shall be due within 14 days. After 90 days, you may be referred to our collection agency. If your account becomes delinquent you will be responsible for all costs associated with the recovery of the debt, including collection agency fees, attorneys fees, and court costs.
PAYMENTS:
Our practice gladly accepts Visa, Mastercard, American Express, Discover, cash, check, or money orders. If your check is returned for non-sufficient funds, you will be responsible for the return fee of $45.00. Please note that all credit card payments are subject to a merchant processing fee.
TREATMENT OF MINORS:
A minor is anyone under the age of 18. The parent(s) or legal guardian(s) must accompany the minor at their appointment. A release will be required prior to services for unaccompanied minors. If the minor arrives without a parent or legal guardian and the required form is not on file, the minor will not be seen and a broken appointment fee will be charged. The parent(s) or legal guardian(s) will be financially responsible for the minor(s).
AUTHORIZATION:
I have read, understand and agree to the financial policy stated above and accept responsibility for payment of all fees/charges incurred with Integrative Dental Wellness.