Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality dental care, so that you may attain optimal oral health. Please understand, payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require that you read, understand and sign prior to any treatment
Payment Options:
We accept the following forms of payment: Cash, Check, All major Credit Cards, Care Credit and The
Lending Club.
Two payments (for treatment over $1,000 that require more than one visit, less than 2 hours long)
Total patient obligation may be divided as follows: 70% due at the first treatment visit, with remaining balance paid at last visit. For fees under $1,000 the full amount is due at the time services are rendered.
Appointments reserved for 2 hours or longer:
For larger cases, longer appointment times will be reserved. A deposit of 50% is required at the time the appointment is scheduled. The remaining 50% is due at the initial prep date. Cancellation of this appointment with less than 48 hours’ notice is subject to a cancellation fee not to exceed 50% of the amount deposited for this appointment.
Treatments today… Payments tomorrow…
We are pleased to offer two payment options in our office, Care Credit and The Lending Club. These options are convenient, no initial payment, low monthly payment plans available for dental treatments of $200 to $25,000. Offering these payment options allows us to make the smile you’ve always wanted financially convenient!
Insurance: We accept all PPO dental insurance plans that are not affiliated with Medicare or Medicaid and because we are out of network, our financial team would be happy to submit the claims with necessary supporting documentation in order to help you maximize your benefits as a courtesy. The insurance contract is an agreement between you and the insurance company. We are not a participating provider. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed. Please note that dental insurance is intended to cover some but not all dental care costs, and not all services are covered by your plan. You are responsible for payment of all services regardless of the payable benefit.
Emergency Appointments: Any emergency visit, regardless of insurance, payment is required in full at time of service. Claims will be sent as a courtesy and any payment made by the plan will be refunded directly to the patient once received.
Changes in insurance: Any changes to your insurance plan should be updated with the office as soon as changes are made in order to ensure an accurate copay. We are typically unable to obtain benefit information the same day as your appointment. Please allow no less than seven (7) business days for the office to obtain a pre determination of benefits.
Finance Charges: Any account balance over thirty (30) days may be accessed a finance charge of $25. We will make every attempt to collect any outstanding balance in attempt to avoid any additional charges.
Returned Checks: Checks that are returned to our office from your financial institution are subject to a $35 returned check fee.
New Patient Appointment Deposit: All new patient appointments require a $95 non-refundable deposit. If you need to amend the date of your appointment, we politely ask for a minimum of 48 hours’ notice. If you reschedule or cancel your appointment less than 48 hours prior to your appointment time, your deposit is unfortunately non-refundable and a new deposit will be required to book any future appointment. We will call or write to patients after a missed appointment to understand the reason for non-attendance and to inform them about any fee. We understand that cancellations are sometimes unavoidable due to illness or emergencies and we will take account of all valid circumstances.
Missed/Cancelled Appointments: Appointments are reserved exclusively for you. As a benefit to you, our valued patient, we may offer to move your appointment to an earlier time if an opening should arise. Please help us to serve you better by keeping your scheduled appointments. We reserve the right to charge and collect $75 for any broken appointments that are one hour or less, and $150 for any broken appointments that are longer than one hour. We understand that cancellations are sometimes unavoidable due to illness or emergencies and we will take account of all valid circumstances. Any appeals about missed or cancelled appointment decisions by a patient should be made in writing to the Practice Manager.
Broken appointments are considered those that are missed (no-show) or cancelled with less than 48 hour advance notice.
I understand and accept the financial and the dental insurance policies listed above and have had any and all questions answered to my satisfaction. I agree to pay for all treatment in a timely fashion as described so as to avoid any additional fees. I hereby authorize my insurance benefits to be paid directly to Dr. Samant. I realize that I am responsible to pay for any deductible amount(s), my co-insurance portion and for any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.