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Stafford Endodontics556 Garrisonville Road, Suite 200, Stafford, VA 2255410703 Spotsylvania Avenue, Suite 101, Fredericksburg, VA 22408OFFICE PAYMENT POLICYPatient:_______________________________________________________________________________ First Name Initial Last NameWe are pleased to welcome you to our office. Our practice has grown as a result of its excellent relationship with our referring dentists and patients. As our patient, please feel free to ask any questions or express any concerns that you may have with Dr. Tolba or the Office Manager.We accept most forms of payment however, we DO NOT ACCEPT PERSONAL CHECKS as payment. We do offer CareCredit as an alternate payment option as well as cash and most major credit cards. If you have insurance, we will file the claim as a courtesy on your behalf and let the insurance pay us. However, your co-payment is due prior to treatment. You will also be responsible for any portion insurance does not pay for any reason. We verify insurance information and benefits however all claims from your general dentist may not have reached processing at the time of our call. We make every effort to estimate your co-pay and ensure we maximize your insurance benefits.INSURANCE: We are preferred providers with most insurances. Your co-pay is due at check-in regardless of whether you have both a primary and secondary insurance carrier. However, if your maximum benefits have been met for the plan year, you will be required to pay in full. If we are not a participating provider with your insurance you are responsible for 100% of our fees. We will file a claim with your insurance carrier and you will be reimbursed. ATTENTION ALL INSURANCE PATIENTS: The amount of coverage paid by your insurance company is based on your insurance company’s “usual and customary” fee schedule. Their fee schedule is normally less than our “actual” charges which we have no control over. Lower payment is a direct result of the plan selected by the subscriber’s employer. If we are not preferred providers with your insurance company, you are responsible for the remaining balance after your insurance has paid its portion. This is calculated based on your maximum benefits available and on the “usual and customary” fee schedule.In addition, the patient or responsible party (parent or guardian) is fully responsible for the total payment of services performed in this office. This includes any amounts not covered by health or dental insurance or prepayment program that the patient or responsible party may have. All remaining balances are to be paid in full within 30 days of treatment date or, if applicable, after your insurance company pays. Balances over thirty (30) days will be subject to a 1.50% monthly interest charge (minimum charge of $1.00). If the account is turned over for legal collection, the patient or responsible party will be liable for all costs of collection including interest, court costs and attorney’s fees. If you have any questions regarding our office policy please feel free to speak with the office manager. By signing below you agree that you have read, understand and agree to comply with the above Office Policies. We make every attempt to confirm your appointment the day before. Please make sure we have an up to date contact number. It is very important to confirm your appointment with us due to the length of time scheduled. Should you not call us back to confirm your appointment it will be cancelled. A charge of $75.00 will be charged for all missed evaluation appointments and a charge of $150.00 will be charged for all missed treatment appointments.______________________________________________________ _______________________Patient/Responsible Party Signature Please Print Name DateRelationship to Patient:_____________________ ................
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