Your One-Stop Specialist for More than a Great Smile

Financial Policy

 

Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that 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 and sign prior to any treatment. It is our hope that this policy will facilitate open communication between us and help avoid potential misunderstandings, allowing you to always make the best choices related to your care.

 

INSURANCE:

Please remember that your insurance policy is a contract between you and your insurance company. Coulter Family Dentistry is not a party to that contract. As a courtesy, we will submit claims to your insurance company and, upon request, can provide a pre-treatment estimate of your anticipated benefits. Please understand that estimates are based on information provided by your insurance company and are not a guarantee of payment or coverage. It is impossible for our office to know every detail of every insurance plan. It is your responsibility to understand your insurance benefits and to contact your insurance company with any questions regarding coverage, limitations, exclusions, deductibles, or benefit levels prior to treatment. If you have questions regarding your estimated benefits or treatment fees, we encourage you to have them answered before treatment begins to help avoid any misunderstandings. It is also your responsibility to provide current, complete, and accurate insurance information. If incorrect, incomplete, or outdated insurance information results in the need for additional claim submissions, corrected claims, or claim resubmissions, an administrative fee of $35.00 may be assessed for each additional claim submission required. Please be aware that some, all, or none of the services provided may be covered by your insurance policy. Any balance remaining after your insurance has processed your claim is ultimately your responsibility, regardless of whether your insurance company pays any portion of the charges.

 

PAYMENT :

Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes but is not limited to: dental fees, surgical procedures, tests, office procedures, medications and also any other services not directly provided by the dentist.

FULL PAYMENT is due at the time of service. If insurance benefits apply, ESTIMATED PATIENT CO-PAYMENTS and DEDUCTIBLES are due at the time of service, unless other arrangements are made. UNPAID BALANCE over 60 days old will be subject to a monthly interest of 1.0% (APR 12%). If payment is delinquent, the patient will be responsible for payment of collection, attorney’s fees, and court costs associated with the recovery of the monies due on the account.

 

MISSED APPOINTMENTS: Unless we receive notice of cancellation 48 hours in advance, you will be charged $30.00. Please help us maintain the highest quality of care by keeping scheduled appointments. I have read, understand and agree to the terms and conditions of this Financial Agreement.