Thank you for choosing Dental Elements for your dental needs. Dental treatment is an excellent investment in your medical and psychological well-being. We are committed to providing you with the best possible care possible to achieve total oral health. Unless other prior financial arrangements are made, payment in full is due at the time services are provided. For your convenience, we accept the following methods of payment: Cash, Check, Money Order, MasterCard and Visa.
- If you have dental insurance, we are eager to help you receive your maximum allowable benefits. However, our office does not guarantee payment or coverage by your insurance company.
- Your insurance policy is a contract between you, your employer and the insurance company. We are not a party to that contract. As dental care providers our financial relationship is with you, the patient, not your insurance company.
- We cannot render services on the assumption that charges will be paid for by an insurance company. While filing the insurance claims is a courtesy that we extend to our patients, all charges are your responsibility from the date the services are rendered.
- Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover. We recommend that you call your insurance carrier to become familiar with your insurance coverage.
- If the insurance company does not pay your balance in full within 30 days, we ask that you contact the carrier to help speed things up.
- If the insurance company does not pay in full within 60 days, we require you to immediately pay the entire account balance. We will not accept responsibility for your insurance companies delay of payment on your claims.
- Balances older than 90 days will be billed a finance charge of 1.5% per month (18% annually) and be released to a collection agency until paid in full.
- Should referral to an attorney or collection agency become necessary, an additional collection charge of 30% of the outstanding balance will be added to the account to defray the costs of collection plus attorney fees and court costs. I understand that my credit rating may be adversely affected should this account be entered for collections.
- All returned checks will have an additional reprocessing fee of $30 charged to the account.
- Once an appointment has been made, please remember that this time has been specifically reserved for you. We reserve the right to charge a fee for all canceled or missed appointments without 48 hours advance notice.
We recognize that temporary financial problems may affect timely payment of your balance. We encourage you to communicate any such problems to us so that we can assist you in the management of your account.
We appreciate your confidence in us and the opportunity to serve you. If you have any questions about the above information, please do not hesitate to ask.
I have read the policies described in this form. I understand and agree to abide by the terms outlined in this financial policy agreement. I understand and accept my financial responsibilities.