ࡱ>    !"#$%&Root EntryZ O2wl'CONTENTS HCompObjVSPELLING(payments and deductibles will also be due at the time services are rendered. ABOUT DENTAL INSURANCE: Our staff understands dental insurance and will be glad to assist you in obtaining the maximum benefits specified in ;your contract. It is important that you realize, however, that ..... 1. Your dental benefit program is a contract between you, your employer and the insurance company. We are not a party to that contract. You, therefore, not the insurance company, are ultimately responsible to pay us for all fees incurred for services rendered. We cannot render services on the assumption that the charges will be paid by an insurance company.  Professional services are rendered to a person, not to a insurance company. Hence, the insurance company is responsible to the patient and the patient is responsible to us. 2. Our fees do not necessarily fall within the usual and customary fee structure determined by your carrier.  Usual and customary means average fees for average dentistry. We do not do  average dentistry. 3. In many instances, the insurance companies still pay for procedures that have been outmoded and do not pay for modern procedures. We offer only modern procedures. While we recognize that economics surely must be considered in any treatment plan, the quality of our procedures will not be governed by whether or not they are covered by insurance. You, the patient, are a co-planner of your dental treatment and all decisions are yours. 4. Please understand that the estimate we give you for expected insurance benefits is just that-an ESTIMATE. As you know, insurance companies seek to collect as much as possible in premiums and to pay out as little as possible in claims. Nevertheless, we will be as accurate as possible in our estiCHNKWKS HTEXTTEXT&FDPPFDPP*FDPCFDPC,FDPCFDPC.STSHSTSH0STSHSTSH02SYIDSYIDP0SGP SGP d0INK INK h0BTEPPLC l0BTECPLC 0 FONTFONT0PSTRSPLC 0:PRNTWNPR.1FRAMFRAM6FTITLTITLF&DOP DOP FPAYMENT POLICY ACKNOWLEDGEMENT Welcome to our office! We are committed to providing you with the best possible dental care utilizing the most modern materials and latest techniques and we seek to do this at the most affordable fees. In order to accomplish these goals, we ask for your understanding and cooperation. FINANCIAL ARRANGEMENTS: Payment for your visits are due at the time of service. There are several methods of payment available. In order that we may have a definite understanding regarding the payment of dental fees, please choose one of the following: A. CASH/CHECK PAYMENT PLAN: Payment for dental services may be paid for at each appointment by cash or personal check. We also accept VISA, MASTERCARD, AND DISCOVER for your convenience. B. MONTHLY PAYMENT PLAN: We offer a variety of monthly payment plans with no money down and some with no interest. It will be necessary to discuss all payment plans with our Financial Coordinator. We can usually arrange a plan that will fit your budget, for our aim is to work with you to enable you to have the Dentistry you need and want done for you now and then pay for it monthly. DENTAL INSURANCE: Should you have dental insurance, we would be happy to help you receive your maximum allowable benefits. We will do all the paper work for you. However, as you know, most dental insurance companies pay only a portion of the dental investment. To avoid disappointment, we strongly suggest that patients contact their insurance company to make certain their dental insurance assumptions are correct. We will estimate for you before each appointment what we feel the insurance will cover and therefore, what portion will be your responsibility. We require that this portion be paid in full at each visit. Co-mates. We will always gladly discuss your proposed treatment plan and its cost and answer any questions you may have. If we work together, we can accomplish our goals of providing you with the best dental treatment available at an affordable cost. We want to be concerned with your dentistry, not financial responsibilities. 5. We require 24 hour notice should you need to cancel your appointment. If we should receive no call of cancellation and you do not show, there will be a $50.00 broken appointment charge. Should you miss more than 3 appointments with no notice, you will be dismissed as a patient. 6. If your balance becomes outstanding for more than 90 days in arrears, we reserve the right to send such information to a debt collection agency. Any fees associated with their collection attempts will be your responsibility and added to your balance. If at anytime you have questions regarding any treatment, fee, or service, please discuss them with us promptly and frankly. WE will make every effort to avoid a misunderstanding, to rectify an injustice, or to preserve a friendship! I understand and agree to this payment policy. __________________________________________ _________________ Signature Date nies still pay for procedures that have been outmoded and do not pay for modern procedures. We offer only modern procedures. While we recognize that economics surely must be considered in an,>@B  6 8 FH*, ""$$&&'''v(x(z(|(~(((2"'( X-X 0Z (2"'( ) @S !B: 8 n~HJ,4n ff.:  "PS" $  088 "PS" $  084 "PS" $  082 "PS" $  084 "PS" $  08 """"$$&'v(x(z(|((X&&&& " . "PS" $ 084 "PS" $  082 "PS" $  088 "PS" $  08:  "PS" $  086  "PS" $  08