Pine City Dental, P.A.
1105 Hillside Ave SW
Pine City, MN 55063
Financial Policy
Thank you for choosing Pine City Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
Payment is expected when services are performed. We accept credit/debit cards, cash, check and flex/HSA cards. Third party, extended payment financing is available upon request and approval with Care Credit. For patients with dental insurance we are happy to work with your carrier to maximize your benefit. As a courtesy to you, we will submit your claims for the reimbursement of your treatment. We can estimate your portion due as services are rendered. If your insurance company pays differently than estimated, you understand that you are responsible for the difference.
Our policy requires payment in full for all services rendered. If your account is not paid within 60 days of the date of service, your account will be evaluated. If no financial arrangements have been made, you will be responsible for legal fees, collections agency fees, interest charges and other expenses incurred in the collection of your account.
The responsibility for payment for services rendered to the child/children of divorced or separated parents rests with the parent who seeks treatment. Any court ordered judgment must be between the individuals involved, without including our facility.
A fee of $25 is charged for returned checks, payable by cash or credit card. This will be applied to your account in addition to the insufficient funds amount.
FINANCIAL OPTIONS AVAILABLE: Name ______
1. ____ I agree to pay in full at the time of service.
2. ____ Patients covered under dental insurance; I agree to pay what my estimated portion
is at the time of service.
3. ____ I would like to wait for my insurance to process. I will then know an exact amount
payable by me. A transaction with your credit carrier will then be processed. A credit/debit/Flex/HSA card number must be left below to choose this option. A
receipt will be mailed to you when a transaction has been completed.
Signature: ______Date: ______
CREDIT/FLEX CARD INFORMATION: ___ Visa / MC / Discover ____ Flex/HSA card
Name on card: ______Expiration Date: ______
Card number: ______Security code (3 digits on card back): ______
*** Please list additional family members you wish to include on all transactions:
______