Patient Financial Policy
Thank you for choosing Metro Square Dental Associates and Deerpath Dental Specialist’s for your dental care
We do not base treatment on what your insurance company deems necessary, or on what theycover. We base treatment on the individual needs of each patient for better dental health. You are ultimately responsible for any charges incurred by you for treatment.
Your insurance policy is a contract between you, your employer, and your insurance company. Our contract with insurance is only for contracted fees and covered services. Uncovered and non-contracted services will be charged at our full fee. We will file your claim as a courtesy to you. It is your responsibility to know your benefits, your limitations, maximums, and exclusions, etc.
You are responsible for your estimated portion at the time of service. We are contracted providers with many insurance companies. If your insurance changes, you must notify us as soon as you become aware of this change as our contracted rates with insurance companies vary and you may have additional co-pays owed.
Pre-estimates are never a guarantee of coverage. We will file a pre-treatment estimate upon request forrecommended treatment. We highly encourage you to contact your insurance with any questions and/or concerns before your appointment if finances are an issue, as you will be held responsible for any and all unpaid balances after insurance has paid or denied your claim.
We will file your secondary claim as a courtesy to you, however, your co-pays are based on your primary insurance and are due at time of service. After both insurances have processed your claim, our fee may change based on coordination of benefits due to our contracted rates varying with each insurance contract.
If a refund is due back to you because of an overpayment that you made, the refund will be issued in the same form of payment after all insurance checks have been received. Refunds are processed monthly.
FSA POLICY: We canonly provide you with an account ledger for submission to your FSA. We will not submit anything to your FSA company on your behalf. Your patient portion is still due at time of service and you can be reimbursed from your FSA independently.
In cases of divorce or separation, the parent authorizing treatment for a child will be the parent responsible for those charges. If the divorce decree requires the other parent to pay all or part of the costs, it is the authorizing parent's responsibility to collect from the other parent.
We are not in network with medical insurance nor do we bill medical on your behalf. If using medical insurance, you must pay our standard fee in full and bill medical independently. Some dental plans require an EOB from medical before considering your dental coverage for medical related services. In this instance, the patient must bill medical and provide the office witha medical EOB so that we can resubmit to dental for possible coverage.
We will apply a 3% finance charge to all balances over 30 days old.There is a service fee of $40.00 for all returned checks.
Past due accounts are subject to collection proceedings. Accounts not paid within 90 days will be turned over to a collection agency and you will be responsible for all collection and legal fees that the practice incurs as a result. We reserve the right to refuse service to any patient that has been placed into collection.
There is a broken appointment fee of $40.00. Wewill make an attempt via phone, e-mail, and/or text message to remind you of your appointment. We reserve the right to dismiss any patient who routinely fails appointments. We will not be held responsible for a broken appointment if we are unable to reach you, or if you do not receive the reminder. We require 24 hours notice for all appointment changes or cancellations to avoid this fee. Cancellations via text or email are not permitted; we require you to call and leave a message or directly speak to the office.
Signature of Patient/Responsible Party:
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