Lonsdale Family Dental Clinic

Matthew J. Stockinger, D.D.S. – Lucas C. Temme, D.D.S.

414 Railway St NW,Lonsdale MN 55046

507-744-2359

Credit Policy ~ Financial Options

Welcome to Lonsdale Family Dental. Our goal is to provide you with affordable dental care. In an effort to avoid any misunderstanding we request that you read and sign this credit policy.

It is the policy of this office that all monthly statements are to be paid-in-full upon receipt, unless prior arrangements have been made with our business office.

It is important that patients with insurance coverage realize that our professional services are rendered to a person, not an insurance company. Hence, the insurance company is responsible to the patient and the patient is responsible to us. We will gladly submit claims to your insurance company for services rendered by us as a service to you. Knowing what your insurance coverage is and your insurance maximums are your responsibility. To avoid misunderstanding, we urge you to contact your insurance company to make certain your insurance assumptions are correct. Your balance with our office is your responsibility whether your dental insurance pays or not.

A service charge is computed at an effective periodic rate of 1.5% per month, which is an annual percentage rate of 18% applied to your previous balance after deducting payments and/or credits during the billing cycle. Statements are generated every 25 days. No service charge will be imposed on balances paid in full within 60 days of service date. Statements are not generated until your insurance has paid

Any outstanding account (over 90 days) may be placed with a professional collection agency. Do not assume that insurance will make payment. Correct any billing error promptly. If you ignore our statements, we can only assume you have no intention of paying for the services we have provided you in good faith. It might become necessary to effect an outside collection agency. This action may mar your credit rating.

All patients are requested to check one of the following plans of payment:

______Will pay treatment in full cash/or check and receive 5% courtesy discount. My portion can be

calculated if I have insurance.

______Will pay in full with major credit card

______CareCredit payment plan (Subject to credit approval)

We do not accept monthly payments. The CareCredit option would be best for you if you feel that monthly payments suit your needs the best. For extensive treatment plans, individual financial arrangements are required before treatment starts. These arrangements can be made with our business assistants and are considered on a case to case basis.

Please direct all business related questions and concerns to our business office at 507-744-2359.

I HAVE READ AND UNDERSTAND THE CREDIT POLICY DESCRIBED ABOVE AND AGREE TO ABIDE BY IT'S TERMS

Signature______

Date______