Lorie A. Moreau, D.D.S.
Family & General Dentistry
1463 St. Charles Street, Suite 1000
Houma, Louisiana 70360
OUR PRACTICE POLICY
We are dedicated to providing you with the best possible dental care and service, and we want to help you understand our financial policies as an essential part of your care and treatment. To assist you, we have the following payment policy. If you have any questions, please feel free to discuss them with our staff. Unless either you or your health insurance carrier has made other arrangements in advance, full payment is due at the time of service. For your convenience we accept all major credit cards.
PRIVATE PAYORS
If you do not currently have insurance coverage, full payment is required at the time of service. All outstanding balances are due at the time of your next check-in. Any problems with payments should be addressed prior to appointment with the Doctor and our staff so that payment arrangements can be made.
INSURANCE POLICY
We have made prior arrangements with many insurers and other health plans. We will bill those plans with which we have an agreement and will collect any required co-payment at the time of service. The co-payment will be collected before you leave our office.
In the event that your health plan decides that a service is “not covered”, you will be responsible for the entire charge. In that event, we will bill you. Your payment is due no later than 30 days from receipt of that statement.
If you have insurance coverage with a plan with which we do not have an agreement, we will prepare and send the claim for you, free of charge. In this case, your insurer will send the payment directly to you. Therefore charges for your care and treatment are due at the time of service.
Any balance due is your responsibility and is due no later than 30 days from receipt of a statement from our office.
COLLECTION POLICY
I agree that if payment is not made in a timely manner, this office should find it necessary to place my account with an agency for collection. I also agree to pay any and all court costs and attorney fees as the rate of 33.3% of $75.00 whichever is greater, on any balance due and owing.
MINOR PATIENTS
For all services rendered to minor patients, the adult accompanying the patient is responsible for payment at the time of service.
MISSED APPOINTMENTS
In order to provide the best possible service and availability to all our patients, it is imperative that you call us for any cancellations 24 hours in advance. As a courtesy to others, please contact us as early as possible if you know you will need to reschedule an appointment. If you fail to cancel within 24 hours of your appointment, you agree to pay a short notice cancellation fee. First notice $25.00 fee, Second notice
$50.00 fee, Third notice $100.00 fee.
I have read and understood the financial policy and I agree to abide by its terms. I also understand and agree that such policies may be changed from time-to-time by the practice.
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Signature of Patient or Responsible Party of a minor Date