Financial Arrangements & Policy
Thank you for choosing our office for your dental health needs. Dr. Rainey, Dr. Fritsche and our team are committed to your treatment being successful and pleasant. The following is a statement of our Financial Policy which we ask that you read and sign prior to treatment.
Our methods of payment accepted includes Cash, Personal Checks, Mastercard, Visa, and Discover credit card payments. We now offer Care Credit & Lending Club. Financing allows no interest payments for your dental care needs. If you have any questions, please feel free to ask.
• ________ Missed Appointments:
Please be aware that when scheduled appointments are missed by either no-showing or without a 48 hours (2 days) notice, the patient’s account may be assessed a $100 fee. This fee is not covered by insurance, and will need to be taken care of prior to scheduling your next appointment. Thank you in advance for committing to your appointed time with us!
• ________ Regarding Your Insurance:
As a courtesy to you, we will help file your dental insurance. In order to help you, we will need to complete insurance information in order to bill your insurance company. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. Please understand that there are many different insurance plans. Payment is determined at the time the claim is received by the insurance company. Dental insurance is only meant to assist you, and not to pay for the completion of your dental care. We can only estimate what your insurance will help you cover. We do the best we can with the information the insurance company gives us. This is not a guarantee of payment. If your insurance company has not paid your account in full within 45 days, we require you to pay the balance in full by the methods above. In the event that your coverage changes, our office must be notified at least 2 business days prior to your appointment to ensure proper verification.
• ________ Usual and Customary:
Our practice is committed to providing the best treatment for our patients and we charge our usual and customary fees to all of our patients. Ultimately you are responsible for the payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Your policy may base its allowances on fixed schedule, which may or may not coincide with our usual fees. Usual and Customary fees by your insurance may be based from the average practitioner in an average office with average staff. We sincerely believe our office is far above those guidelines.
The adult accompanying a minor and the parents (or guardians) are responsible for full payment.
I understand and agree that all services rendered to me, my dependents, or others assigned by me to my account are charged directly to me. I further understand I am personally responsible for payment. Should the fees for the professional services not be paid in accordance with the provisions herein, applicable finance charges and disbursements, allowances and cost can be applied to all past due amounts at the rate of 1.5% per month (18% annual rate.) If the account is in default and turned over for collection, a collection fee will be added.
name of patient (& parent/guardian)