Adams Dental Center



Adams Dental Center

Kent E. Dodson, D.D.S., P.C.

Office Policy 2015

It is the goal of this office to provide you with the finest quality dental care possible. We believe that a clear definition of our financial and insurance policies will allow the patient, doctor, and staff to concentrate on the most important issue being, the treatment and maintenance all of your specific dental needs.

********All deductibles and estimated co-payments must be paid on the day of service. No exceptions.********

UPDATE: As of January 1, 2015 we are no longer accepting partial payments or post-dated checks for any dental treatment including fillings, crowns and prosthetics. We will send a pre-treatment estimate request to your insurance, if you request one to be sent. If services are performed before the estimate is received back from insurance, we will calculate the best we can, your portion that will be due the day of treatment.

PLEASE NOTE: A $30.00 charge may be assessed for any missed appointment and a $20.00 fee may be assessed for any cancelled appointments that 24-hour notice was NOT given.

As a courtesy to you, we will file your dental insurance claims for you. By signing this office policy, you are assigning all insurance benefits to us. If you prefer to submit your own dental claims or your insurance company sends payment directly to you, payment in full will be required on the day of service and you shall be provided with a copy of the services performed. If you do not have insurance and are self-pay, payment is required at the time of service in full.

Please understand that we can only estimate your insurance company’s payment. Any balance due after an insurance payment is received is your financial responsibility and a bill will be sent to you no later than 30 days after receiving insurance payment. Any payment received in excess of your balance will be credited to your account. Upon request, we will send you a refund check or you may also apply this credit toward any future co-payments if you continue treatment with us.

Your dental insurance is a contract between you, your employer (if it is a group dental plan) and the insurance company. The dentist is not a party to the dental insurance contract. We do not guarantee that an insurance company will reimburse for services at the “usual and customary fee”. Not all dental services are covered benefits in all dental (or medical) insurance contracts. The filing of insurance claims is a courtesy that we extend to our patients; however, all charges are your responsibility from the day services are rendered regardless of insurance coverage.

We accept cash, check, money order, Care Credit, and all major credit cards. Any balance over 30 days old will be assessed a finance charge of 18% A.P.R. (1.5% per month). If the account goes 90 days past due and you are sent to our collection agency because of failure to pay, then you will be dismissed as a patient immediately. We will forward your dental records to the dentist of your choice upon receipt of written permission to do so.

For your convenience, we are able to offer low monthly payments to our valued patients through Care Credit. If interested, please ask for an application. If you are relying solely upon these credit services to pay your account, approval from the financial institution must be received before dental services can begin.

( Cash or check the day of treatment (5% discount applied for payment in full).

❑ Dental insurance. I will pay my estimated portion by cash, check or credit card on the day of treatment.

❑ Visa, MasterCard, Discover, American Express or Care Credit.

❑ I wish to apply for a Care Credit Account (12 months interest free financing).

I have read and agree to the office policy above

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Please indicate the manner in which you will to handle your account with us:

Date

Signature of patient OR parent/guardian if patient is under 19

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