FINANCIAL POLICY - Klermont 4 Kids



FINANCIAL POLICY

Thank you for choosing us as your health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. If we are an in network provider for your insurance you will realize a substantial cost savings.

PATIENT CO-PAYS AND DEDUCTABLES:

PAYMENT IS DUE AT TIME OF SERVICE. WE ACCEPT CASH, CHECK, OR CREDIT CARDS. FINANCING MUST BE ARRANGED PRIOR TO TREATMENT AND MUST BE APPLIED FOR AND APPROVED.

FILING INSURANCE CLAIMS:

We file all dental claims from our office as a courtesy to our patients. However, we cannot file your claims properly if we are not given the correct insurance information at the initial appointment or as soon as you obtain the insurance. If you fail to provide us with all of the insurance information this may cause your claims to be denied by your insurance and if the problem is not resolved within 30 days your account will be sent to collections. Although you may have dental coverage we do require you to pay your portion of the bill at the time of service. Please be aware that some and perhaps all of the services provided may be covered at only a percentage of the total cost. Specific exclusions in your insurance policy coverage can result in you being 100% responsible for the fees. The patient is responsible for the percentage that is not covered. (Portion not due by your insurance company) You are ultimately responsible for the full balance of any bill whether your insurance pays or not. Your specific insurance policy is a contract between you and your insurance company. We are not a party to this contract. Please review your insurance coverage with your insurance company. We also do not accept responsibility for any misunderstandings between expected coverage and actual coverage. You must seek clarification from your insurance company prior to treatment if you want to be 100% certain of your expected costs. We will give you an estimate based on the information provided by your insurance company. We will attempt to help you understand your coverage but we are not insurance experts for the vast number of employers, insurance companies and policies. If your insurance company has not paid your account in full within 90 days the balance will be due by you. If for any reason we have to turn your account over for collections, you agree to pay any and all court costs, attorney fees and collection fees. If you do not agree with this insurance filing policy you are entitled to file your own insurance claims, however you will have to pay the entire bill including the insurance portion at the time of service.

MISSED APPOINTMENTS

Unless canceled 24 hours in advance, our policy is to charge $44.00 for each missed/late cancellation/re-instatement fee of appointments. Please help us to serve you better by keeping your scheduled appointments.

RUNNING LATE

If you are more than 30 minutes late for a regular appointment or 10 minutes for a cleaning appointment, you may be asked to reschedule. If we are more than 30 minutes behind you may request to reschedule. If you are running late please call ahead and let us know. Courtesy is a two way street. If we are behind please remember our office accepts emergencies and children, BOTH of which are unpredictable. Some children (and adults) are extremely frightened and require more time than expected. Your understanding is greatly appreciated. Consider that it could be you or a family member that need the additional time or have a dental emergency.

INCIDENTAL FEE’S (Subject to change without prior notice)

1) Missed Appointments/ Re-Instatement Fee/ Late Cancellation (less than 24 hours notice) fees are $44.00. We reserve the right to refuse service to patients after a second occurrence of these policies.

2) Returned check fee NSF $30.00 Closed Account $40.00. Clermont county court check mediation fee $17.00.

3) To release your records (x-rays) to another dental office $14.00

4) If you are seeing multiple dental providers please keep us informed of that treatment so that we may coordinate your care and ensure that services are not duplicated. If your insurance company refuses to pay our office for duplicate services you will be responsible for that cost and/or dismissed from our practice.

5) Infection Control / Sterilization fee per patient per visit of $5.00

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my dependents or me during the period of such dental care to third party payers and / or other health practitioners. I authorize and request my insurance company to pay directly to the dentist. I understand I am financially responsible for all charges not covered by this assignment. If I do not pay the balance within 25 days of the monthly billing date, a late charge may be applied to my unpaid balance. I realize that failure to keep this account current may result in my being unable to receive additional service. In the case of default on payment of this account, I agree to pay any collection costs and reasonable attorney fees incurred while attempting to collect on this amount or any future outstanding account balance.

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SIGNATURE DATE

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