Patient Financial Policy - Vista Dental Center printable pdf download

Vista Dental Center

Dr. John M. Garza, DDS

Office: 281-991-6530

6429 Fairmont Parkway Suite 101

Fax: 281-991-6553

Pasadena, Texas 77505

FINANCIAL POLICY

We value you as a patient and are committed to providing you with the best dental care.

We want you to have a complete understanding of you financial responsibilities for the

services to be provided. To assist us in achieving these goals, we ask that you review our

financial policy. This is an agreement between Vista Dental center, as creditor, and the

Patient/Debtor named on this form. In this agreement the words “you,” “yours” mean the

Patient/Debtor. The word “account” means the account that has been established in your

name to which charges are made and payments credited. The words “we,” “us,” and

“our” refer to the doctors and staff at Vista Dental Center.

By executing this agreement, you are agreeing to pay for all services that are received.

Payments: Unless payment arrangements are approved by us in writing, the balance on

your statement is due and payable at the time services are rendered. The balance on

your account is considered past due if not paid by the end of the month. All treatment

charges are the responsibility of the patient or responsible party regardless of

insurance coverage. In the event of non-payment or responsible party agrees to pay all

the cost of collection including, but not limited to attorney fees, court cost, collection

agency fees, etc.

Insurance: we will be happy to help process your claim for reimbursement or you may

assign your benefits to the doctor as partial payment toward services rendered. This can

de done after we have had the opportunity to verify your insurance benefits. At this time

of your appointment, you will be expected to pay your deductible, as well as any

portion of the treatment fees that we estimate will not be covered by your insurance

policy or the remaining amount due in the event that your insurance company

makes a lower payment than estimated. Because of insurance policy changes and/or

necesssary changes in treatment plans, your dental coverage may vary from this

estimated treatment calculation or your carrier’s pre-estimate. If your insurance company

has not paid the full balance of the claim within 60 days from treatment date, you will be

responsible for paying the balance. Please remember that your insurance is a contract

between you and your insurance company and/or employer. Our dental practice is

not a party to the contract. We recommend that any questions regarding the amount of

insurance coverage for the specific treatment be discussed directly with your insurance

company or your employer.

Past due accounts: If your account becomes past due, we will take necessary steps to

collect this debt. If we have to refer your account to a collection agency, you agree to pay

all the collections cost which are incurred. If we have to refer collection of the balance to

Patient Financial Policy - Vista Dental Center