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Financial Policy

Our staff at Northern Lights Dental Clinic is committed to providing you with the best possible dental care. Our fees reflect our professional commitment to excellence. If you have dental insurance, we are happy to help you obtain your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy. We thank you for taking the time to read and understand the policy below.

For the convenience of our patients, we offer the following methods of payment of fees.

Non-Insured Patients:

Payment is expected at the time of service for treatment performed that day unless prior arrangements have been made. For your convenience, we accept cash, personal checks, money orders, Discover, American Express, Mastercard, or Visa.

Insured Patients:

▪ As a courtesy to patients we will file an insurance claim on your behalf, however you must supply, prior to treatment, all the necessary information for filing.

▪ All ESTIMATED co-payments and deductible payments are expected at the time the services are rendered.

▪ We will gladly discuss your proposed treatment and answer any questions relating to your insurance to the best of our ability, however:

o Your insurance is a contract between you, the insurance company, and your employer. We are not a party to that contract. Therefore you (not the insurance company) are responsible to us for all our fees for services rendered to you. The filing of insurance claims is a courtesy that we extend.

o Our estimate of insurance coverage is only an estimate based on the information available to us. It is ultimately the patient’s responsibility to know the details of the insurance coverage, including percentages payable, waiting periods, deductibles, yearly maximums, services not covered under the plan, and any other related information.

▪ If your insurance has not paid their liability within 60 days, the balance then becomes the patient’s liability.

▪ All insured patients are required to sign an assignment of benefits, directing the insurance company to remit payments to our office. If you receive a check from your insurance company, which should come to our office, we ask that you endorse the check making it payable to “Northern Lights Dental Clinic”. Mail it to our office along with a copy of your EOB to, 2595 St. Nicholas Dr., North Pole, AK 99705. Then we can apply payment properly to your account.

▪ Our fees are per service and fall within most insurance guidelines for “usual, customary, and/or reasonable fees”. Insurance policies base their payments on UCR fees. Charges in excess of UCR are not considered for payment by insurance, but are the responsibility of the patient.

▪ Not all services are covered under all policies; some insurance companies arbitrarily select certain services they will downgrade coverage on or not cover at all.

Finance charges of 4% per month will be applied to balances over 60 days. Accounts will be considered delinquent after 90 days. Delinquent accounts will be placed with a private collection agency or be filed with the court as a small claims case. Any and all accounts placed with a collection agency or small claims will be subject to all reasonable collection and court costs. Returned checks will be subject to $35 fee.

To protect our office from Patient Identity Theft, a photo ID will be required to be on file for all adult patients.

Please be aware, any parent bringing a child to our office is responsible for payment of all services rendered.

Again thank you for choosing Northern Lights Dental Clinic as your dental provider. We appreciate your trust and the opportunity to serve you.

I understand and agree that, regardless of my insurance (if applicable), I am ultimately responsible for the balance on my account for all the charges and services rendered. I have read all the information on this sheet.

If you have any questions, please feel free to inquire before signing below.

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Patient/Responsible Party Signature Date

Rev. 9/6/18

Cancellation Policy/No Show Policy

1. Cancellation/No Show Policy for Doctor Exams/Cleaning Appointments

We understand that there are many times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment with enough notice, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to seemingly “full” appointment book.

If an appointment is not cancelled at least 24 hours in advance you will be charged a $50 fee; this will not be covered by your insurance company.

2. Scheduled Appointments

We understand that delays can happen however we must try to keep the other patients and doctors on time.

If a patient is 15 minutes past their scheduled time we may have to reschedule the appointment.

3. Cancellation/No Show Policy for

Restorative/Oral Surgeries/Periodontic/Endodontic/Crown Procedures

Due to the large block of time needed for surgeries, endodontic and crown procedures, last minute cancellations can cause problems and added expenses for the office.

If a surgery, endodontic or crown procedure is not cancelled at least 48 hours (2 days) in advance you will be charged a $75 fee; this will not be covered by your insurance company.

4. Account Balances

We will require that patients with self-pay balances do pay their account balances to zero prior to receiving further services by our practice.

Patients who have questions about their bills or who would like to discuss a payment plan option may call and ask to speak to a business office representative with whom they can review their account and concerns.

Patients with balances over $100 must make payment arrangements prior to future appointments being made.

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Print Patient Name Signature Patient/Guardian Date

9/6/2018

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