FINANCIAL POLICY
In
order to deliver comprehensive quality dental care for your children at reasonable
fees, it is important to control costs. It is unfair to pass the additional
costs of collecting delinquent accounts of a few to all of our patients in
the form of increased fees. Therefore we expect each parent or legal guardian
to accept financial responsibility for the fees involved in the dental treatment
of their children. We trust that you understand and appreciate the need for
a clear policy regarding your account. Please read the financial information
and sign at the end. Please feel free to ask any questions of our staff.
You are expected to pay for treatment at the tithe of service.
Special payment arrangements may be available if made in advance
of the appointment. If necessary, a credit report will be run. We accept cash,
check, VISA, and MasterCard. If you have dental insurance, we may be able
to assist you in filing your claim as a courtesy to you, However. professional
care is rendered and charged to the patient and not to the insurance company,
and therefore the responsibility for payment remains with you.
All accounts are covered under the following provisions:
1)
Payments made in full by cash or check on the day of service are given
a 5% courtesy allowance. For restorative work, if the total estimated treatment
plan is isaid in full by cash or check at the initial restorative visit, the
5% courtesy is offered. MasterCard and Visa are accepted without the courtesy.
2) If the total of your visit is under $75: we expect
payment in full. We will give you an itemized copy of your fees for your records
and an insurance copy if applicable.
3) For children of divorced parents, the parent bringing
the child for treatment will be held responsible for payment at the time of
service unless other arrangements have been made in advance. We will provide
you with any information for the other parent when necessary and appropriate.
4) For patients with dental insurance, we recommend
the best dental care for your child, regardless of dental insurance limitations.
We have no role in determining the type of coverage your employer provides
for you. We may be able to electronically file your insurance claim for you
as a courtesy. However, we have no influence nor responsibility for the correct
handling or receiving of your claim once we receive confirmation of successful
transmission. We will provide you with appropriate materials for you to expedite
the processing of your claims should questions arise. If your child needs
restorative work. we may accept a partial payment on the day of service based
on our office guidelines. We will file with your primary carrier; however,
we do not handle secondary insurance filing. Insurance claims remaining outstanding
for more than forty-five (45) days after treatment, regardless of the reason,
are considered past due. and subject to finance charges. We will provide you
with appropriate additional materials after the account has been paid.
5) Any accounts remaining unpaid over sixty (60) days
are delinquent and will incur finance charges at 1.5% per month.
6) All returned checks are assessed a $20.00 charge.
Since your bank must, by law, inform you of a non sufficient funds check,
we expect you to contact us to make arrangements for settling the full amount
of the check plus $20.00, within five (5) days. All other policy provisions
as noted above apply.
7) All accounts remaining delinquent for 90 days
will result in the immediate dismissal of your children from the practice,
and your account will be forwarded to the credit bureau for processing as
a bad debt.
If you have any questions concerning your account, please
contact us during business hours. If we do not hear from you, we will assume
everything is correct.
We thank you for your cooperation and look forward to providing
exceptional dental care for your exceptional child.
Dr. John C. Pfefferle, Dr. Don J. Kindrachuk, and Staff
I have read and fully understand the above Financial Policy.
Name __________________________________ Date_______________
Relationship to Patient _______________________________________
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