Dental Registration And History Form (Page 4 of 7) in pdf

Atwood Family Dental Financial Policy

Thank you for choosing our office for your dental needs. We realize that every person's financial

situation is different. For this reason, we have worked hard to provide a variety of payment

options to help you receive the dental care you need and deserve that allows you to enjoy a

healthy, beautiful smile with respect to your budget. Dental treatment is an excellent investment

in an individual's medical and psychological care. We are always available to answer your

questions or assist you in any way we can.

To maintain the practice operations and prevent potential misunderstandings, we ask patients to

accept and adhere to the following financial arrangements regarding their dental treatment.

Optional Payment Terms:

Pre- Payment Discount: If the patient portion is over $1000 we offer a 5% accounting

courtesy for patients who pay their portion (that part not expected to be covered by insurance) for

the total treatment plan the day the treatment plan is presented. This allows us to arrange all

needed appointments in advance and order any materials specific to your needs, and rewards you

with a 5% discount. Payment by cash or check is accepted for the discount.

Major Service Payment Option: We offer a two-payment option for Crown, Bridge,

and Denture treatment. We ask that you pay one-half of your payment at or prior to the first

appointment and the second half at or prior to the seat appointment.

Interest Free Term Loan: By arrangement with Care Credit, we offer our patients,

upon approval, an interest free term loan (up to 12 months) with no down payment, no annual fee,

and no prepayment penalty. Generally the application form can be completed online and

approval given within a few minutes at our office front desk.

Payments are expected either in advance, or at the time services are rendered. We accept cash,

checks, debit cards, all major credit cards, and Care Credit.

Dental insurance polices are an agreement between the insurance company and the policy holder.

We accept insurance with the understanding that any payment not received from insurance within

30 days of filing becomes the patient's responsibility. For those patients with secondary

insurance, we will continue to file secondary insurance, however, the patient is responsible for

payment of services not covered by the primary insurance, as the secondary insurance will

reimburse the patient directly.

Patients who miss appointments or cancel on short notice (less than 24 hours) will be asked to

make a reservation deposit for subsequent appointments. Please note that appointments cannot be

cancelled or rescheduled via the answering machine.

By signing below, you are stating that you agree with above options and terms and will proceed

accordingly.

Again, thank you for choosing Atwood Family Dental.

Patient signature:_____________________________Date:_______________________

Dental Registration And History Form Page 4