CHOULES FAMILY DENTISTRY FINANCIAL/OFFICE POLICY
Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.
All patients must complete our Information and Insurance form before seeing the doctor.
FULL PAYMENT IS DUE AT TIME OF SERVICE
WE ACCEPT CASH, CHECK, VISA, MASTERCARD, DISCOVER & AMERICAN EXPRESS
We may accept assignment of insurance benefits on your first visit; we do require that your portion and if subject to a deductible, be paid at the time services are rendered. Due to all various insurance plans now in effect in the market place, it has become a very complicated process to become familiar with each plan. We therefore are requiring your cooperation so that we may better serve you and give you the proper dental care you deserve without spending an exorbitant amount of time obtaining benefit information from your insurance company. It is your responsibility to know all of the information required by your insurance plan to avoid any confusion or non-payment of services. Dental claims not paid within 90 days, becomes patient responsibility and balance on account is due immediately. THE BALANCE IS YOUR RESPONSIBILITY WHETHER THE INSURANCE COMPANY PAYS OR NOT.
Please be aware that an authorization from you insurance company for treatment is not a guarantee of payment.
Please not that failure to cancel your appointment may hinder another patient’s ability to be seen by the doctor. Therefore, we request a courtesy call 24 hours prior to the patient’s scheduled appointment, otherwise you may be subject to a “no show” fee. Repeated “no shows” may be subject to discharge from the practice.
I understand that I am responsible for any charges that may be incurred, such as collection and/or attorney charges, if and when it becomes necessary.
I HAVE READ AND UNDERSTAND THE FOREGOING FINANCIAL/OFFICE POLICY, AND AGREE TO ABIDE BY THE TERMS OF THIS POLICY.