Patient Financial Information Form printable pdf download

- 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.

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Signature ( Responsible P arty)

D ate

Patient Financial Information Form