Thomas S. Walther, D.D.S.
FINANCIAL POLICY
In order to enhance communication and promote understanding regarding this office’s financial and missed appointment policies, please read through the following information. After reading, please provide your signature at the bottom indicating that you fully understand these policies. This form must be signed in order to proceed with your scheduled appointment. If you have any questions or concerns, please do not hesitate to ask. We are here to help you! Thank you.
INSURANCE: We are happy to file claims with your primary and secondary insurance carriers as a courtesy for our patients. Please understand that each patient is ultimately responsible for the cost of services rendered. Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. Our financial relationship is with you, not your insurance company. We have a separate agreement with them.
· You may be responsible if your insurance company does not pay for a service. Not all services are covered benefits in all contracts.
· We will do our best to estimate insurance coverage and patient portions due. We will send pre-treatment estimates for services over $500, or at your request. If the insurance company does not pay the full amount anticipated, the patient is responsible for the difference.
· It is your responsibilty to inform us of your current insurance status and any changes in that status. If the information you have given us is incorrect and it results in a balance due, you are responsible for payment of the balance.
PATIENT PAYMENTS: Payment is due at the time services are provided. For more extensive cases (crowns, bridges, implants, partials, veneers, etc.) 50% of the patient portion is due at the start of treatment, including any deductible, and the remaining 50% at the last appointment. A signed copy of the financial agreement is necessary prior to treatment. We accept cash, checks, and Visa, MasterCard, Discover Card, and American Express. We also offer Care Credit® as a financing option.
DHMO/DMO INSURANCE: Co-payment for each procedure is due at the time of service. Any payment arrangements MUST be made prior to treatment. We will provide a copy of services to be provided, including your patient copays and current CDT codes. A signed copy of the financial agreement is necessary prior to treatment.
ACCOUNT STATEMENTS: We use a dental billing company to process our patient payments and insurance claims and payments. First Pacific Corporation (FPC) sends monthly statements reflecting the patient’s balance and indicating payments both from the patient and insurance company. All patients with a balance will receive a statement. Late payment, interest and finance charges will be applied to accounts that do not make the minimum payment by the indicated due date. Our office will supply you with a copy of FPC’s truth in lending information, at your request. If you have any questions regarding your statement, please call FPC at 1-800-574-7064.
Some patient accounts are billed directly through our office, not FPC. Payment for dental services rendered is expected to be paid in full upon receipt. Any payment arrangements MUST be made prior to treatment.
MISSED APPOINTMENTS: We request notice of 24 hours for cancellation of appointments. If appropriate notice is not given, a charge of $25.00 will be assessed to the patient’s account. We understand that sometimes last minute cancellations are unavoidable, and in certain circumstances the assessment may be waived. Repeated late cancellations or no shows may result in additional charges or dismissal from our practice.
REFUNDS FOR UNFINISHED TREATMENT: Please understand that if a patient decides to discontinue treatment after it has been started, a full refund will not be given.
PAYMENT PREFERENCE (please check a box):
1. I would like to pay my estimated patient portion by check, debit or credit card. □
2. I would like to apply for an extended payment plan through Care Credit®. □
Date: ______Name: ______Patient Signature (parent if minor): ______