Arizona Healthy Smiles

Shawn Young, DMD

1840 E. Baseline Rd. Ste. C-7 | Tempe AZ, 85283 | 4804565457|

Written Financial Policy

Thank you for choosing Shawn Young, DMD. 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 Options:

You can choose from:

- Master card, American Express, Discover Card, Cash or Check, Visa

- NO INTEREST¹ Payment Plans² from CareCredit

  • Allow you to pay over time with NO INTEREST¹
  • Convenient, low monthly payment plans² also available
  • No annual fees or pre-payment penalties

PREFFERRED METHOD OF PAYMENT: Please circle the one that applies:

Cash/Check on Day of treatment Care Credit Visa/MasterCard/American Express/Discover/Debit card

Credit Card #______Exp. date______

Cardholder Signature______Security code______

Person responsible for this account: Relationship: Phone #

______

Address:

______

Patient Name:______

______

Patient, Parent or Guardian Signature Date

For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment.³ We will gladly discuss your proposed treatment and answer any questions you may have.

You must realize, however, that:

1. Your Insurance is a contract between you, your employer, and the insurance company.

We are not a part of that contract. We encourage you to talk to your insurance company

and familiarize yourself with your plan.

2. Not all services are a covered benefit in all contracts. Some plans arbitrarily select

certain services they will not cover. Any amount not paid by your insurance, regardless of the reason, is your responsibility. We therefore require a credit card to be on file for any balance not paid by your insurance company.

BE AWARE that your insurance company will be mailing an explanation of benefits (EOB) to you,

if your insurance company pays less than the estimated portion you can at that time contact them

so they can answer any questions you may have. We will also be receiving a copy of your EOB.

If there is a discrepancy between the amount the insurance company pays and the amount we

estimated they would pay, we will send you a statement for the unpaid portion.

When you receive the statement please contact our office to arrange payment.

If we do not hear from you within 10 days of the statement date we will apply the balance to the

credit card we have on file.

  1. Patient will be liable for all costs incurred if the account is forwarded to a collection agency.

$25 is charged for patients who miss or cancel more than 1 time in a calendar year without 24-hour notice.

Shawn Young, DMD charges $25 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian SignatureDate

Patient Name (Please Print)

¹If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.

²Subject to credit approval

³However, if we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.