FINANCIAL AND APPOINTMENT POLICY



FINANCIAL AND APPOINTMENT POLICY

FOR DR. BRENT CHAPMAN AND DR. ADAM SHIPP

FOR INSURED PATIENTS: As a courtesy to you we contact your insurance company to verify your benefits and calculate your estimated co-payment. Please understand your co-payment is an estimate and not a guarantee. Upon payment from your insurance, any remaining balance will be your responsibility. A statement will be sent and is due upon receipt. If your insurance pays more than we anticipated, we will send you a refund. We are participating providers with MET LIFE PPO, DELTA DENTAL PPO PREMIER, AETNA PPO & DMO, BLUE CROSS ID PPO & TRADITIONAL, GUARDIAN AND CIGNA PPO-RADIUS. However, we submit claims to all insurance companies.

FOR UNINSURED PATIENTS: We do require you to pay for the entire treatment on the day of service.

PAYMENT OPTIONS:

( CASH ( CHECK ( CREDIT CARD (We accept all major credit cards)

IF A PERSONAL CHECK IS YOUR OPTION OF PAYMENT WE RESERVE THE RIGHT TO VERIFY FUNDS BEFORE SERVICE IS RENDERED. ANY CHECK THAT IS RETURNED WILL BE CHARGED A $25.00 FEE.

← If you need to make payments we have an agency (CareCredit) that we participate with. You can apply by telephone from our office before treatment begins. (6 month, no interest option only)

We do charge 2% monthly interest on all accounts with a balance 60 days or more overdue. For insured patients interest will be charged 60 days from final insurance payment that result in a balance. Any account sent to collections will be charged a 25% collection fee on top of balance due.

If you miss or reschedule an appointment without at least 24-hour notice you will be charged a fee of $50.00.

If you have any questions concerning our policies please ask to speak with Mary.

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Patient or Guardian Signature Date

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