Patient Financial Information Form


-­   P atient   F inancial   P olicy   -­  
801   E ast   M edical   C ourt  
Post   F alls,   I D   8 3854  
Phone:     2 08.773.1559         F ax:     2 08.773.9959  
In   t he   i nterest   o f   g ood   c ommunication   a nd   o ur   c ontinued   c ommitment   t o   p rovide   t he   h ighest   q uality   o f  
dental   c are   a vailable   t o   a ll   o f   o ur   p atients,   w e   h ave   e stablished   a   P atient   F inancial   P olicy.     I t   i s   o ur   h ope,  
that   t his   p olicy   w ill   f acilitate   o pen   c ommunication   b etween   u s   a nd   h elp   a void   p otential  
misunderstandings,   a llowing   y ou   t o   a lways   m ake   t he   b est   c hoices   r elated   t o   y our   c are.  
We   a re   c ommitted   t o   s upport   y ou   i n   u nderstanding   y our   d ental   h ealth,   a nd   w ill   a lways   p resent   y ou   w ith  
the   b est   d ental   s olution   p ossible   t o   t reat   y our   p ersonal   s ituation.     T o   m ake   t hese   s ervices   c omfortably  
affordable,   w e   a re   p leased   t o   o ffer   y ou   t he   f ollowing   p ayment   o ptions.     P lease   s elect   o ne:  
1. Cash   o r   C heck  
2. Visa,   M asterCard   o r   D iscover  
3. Care   C redit  
We   w ill,   a s   a   c ourtesy,   p rocess   y our   i nsurance   b enefits   i n   o ur   o ffice.     A ll   q uestions   r egarding   y our  
insurance   b enefits   m ust   b e   a ddressed   t o   y our   i nsurance   c arrier.  
I   a gree   t hat   I   a m   f ully   r esponsible   f or   t he   t otal   p ayment   o f   a ll   p rocedures   p erformed   i n   t his   o ffice—this  
includes   a ny   t reatment   t hat   i s   n ot   a   b enefit   o f   a ny   d ental   i nsurance   t hat   I   m ay   h ave.     I   u nderstand   t hat  
any   e stimated   p ortion,   n ot   c overed   b y   i nsurance,   i s   d ue   a t   t ime   o f   s ervice   f or   a ll   s ervices   r endered.     I  
understand   t hat   a ll   s ervices   a re   d ue   t o   b e   p aid   w ithin   n inety   ( 90)   d ays   o f   d ate   o f   s ervice,   r egardless   o f  
whether   o r   n ot   m y   i nsurance   b enefits   h ave   b een   r eceived.     O ne   a nd   a   h alf   p ercent   ( 1.5%)   p er   m onth  
interest,   e ighteen   p ercent   ( 18%)   p er   y ear   w ill   b e   c harged   o n   a ccounts   3 0   d ays   f rom   t he   t reatment   d ate.      
Please   m ake   y our   q uestions   a nd   c oncerns   k nown   t o   o ur   A ccounts   M anager   w ho   i s   h appy   t o   d iscuss   t his  
policy   a nd   e nsure   t hat   y ou   h ave   a n   o utstanding   e xperience.  
            _ ___________________________  
Signature   ( Responsible   P arty)  
                                      D ate  


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