KURT E. DELIUS, .D.D.S., M.S.

Periodontics and Dental Implants

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10123 Lake Creek Parkway Bldg. 1

Austin, Texas 78729

(512) 335-3600

OUR FINANCIAL & INSURANCE POLICY

Thank you for selecting our office for your periodontal care. We are committed to providing the highest quality care for our patients, using the latest techniques. We want all aspects of your treatment to go smoothly. We feel it is important for you to understand that payment of your bill is part of the treatment process and that you should know our policy and your responsibility regarding it. With this in mind, we require that you read and sign our Financial Policy statement prior to any treatment.

FULL PAYMENT IS DUE AT THE TIME OF SERVICE.

WE ACCEPT CASH, CHECKS, VISA/MASTERCARD, AND DISCOVER.

Regarding Insurance

Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy, we will assist you in filing claims with your insurance company so you may be reimbursed. We may accept assignment of insurance benefits after your second visit. In the event that we do accept assignment of benefits, we require that your treatment be pre-approved by your insurance company. However, we do require 75% of the bill to be paid at the time of service. The balance remains your responsibility whether your insurance company pays or not. If your insurance company has not paid your account in full within 45 days, the balance will be due. We need your insurance information and an original claim form to be able to help you file your claim. Please be aware that our services are not covered under the Medicare Program.

With regard to insurance plans where we are a participating provider, all co-pays and deductibles are due prior to treatment. In the event that your insurance coverage changes to one where we are not participating providers, refer to above paragraph.

Usual and Customary Rates

Our fees are charged according to what is usual and customary for our area. Our practice provides the highest standard of treatment for our patients. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Minor Patients

The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan, Visa/MasterCard, or Discover; or unless payment by cash or check at the time of service has been verified.

Missed Appointments

Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at a rate of a normal office visit. When you schedule an appointment with our office, we consider it confirmed and do not give it to any other patient. Please help us serve you better by keeping scheduled appointments.

Thank you for understanding our Financial Policy. Please do not hesitate to discuss any questions or concerns with us.

I have read the Financial Policy for Kurt E. Delius, D.D.S., M.S. I understand and agree to this Financial Policy.

XDate

Signature of Patient or Responsible Party

Printed Name of Signature