Financial Policy s1

FINANCIAL POLICY

ALL PATIENTS

In consideration for Northwood Dental – Cosmetic and Family Dentistry to provide you with dental treatment, you agree that all fees and co-payments are due and payable on the day that treatment is rendered to you unless other payment arrangements have been agreed to in writing by Northwood Dental. Cash, check, Visa®, Mastercard®, Discover®, American Express®, Care Credit® and CitiBank Health Card ® are all acceptable methods of payment.

We kindly request 48 hours notice to change an appointment time. Changes must be made with our staff during normal business hours. Appointments can not be changed by voicemail or e-mail. A charge of $50 may be applied for all appointments which are not kept.

If your account balance is not paid in full within 30 days of treatment being rendered, you agree to be subject to interest charges of .66% per month (8% apr). In the event that your account becomes delinquent and is not brought current, you understand that in addition to your outstanding balance, you agree to be responsible for all collection costs and reasonable attorney fees incurred by Northwood Dental or on behalf of Northwood Dental. You understand that you are solely responsible for payments in full of all accounts you may have with our office.

PATIENTS WITH DENTAL INSURANCE

You are solely responsible for payment to Northwood Dental for dental treatment rendered even if you are covered by dental, medical or accident insurance. As a service to you Northwood Dental will file your insurance claim with your insurance carrier. We ask that you provide our office with correct and /or updated insurance information at each appointment or whenever you have a change in coverage.

Since some insurance programs provide limited coverage, we urge you to be fully aware of the provisions of your particular plan. Northwood Dental assumes no liability or responsibility for knowledge of your particular plan provisions or limits. We will, if requested, submit a pre-determination of benefits prior to treatment being provided. Please be aware that a pre-determination of benefits is based only on your current eligibility and contract benefits and submission of other claims from this or another office and /or any changes in your eligibility may alter your available benefits. Northwood Dental is not responsible for misinformed benefit information given to you by your insurance carrier. If you disagree with the benefit allowance paid, we ask that you contact your insurance carrier.

In signing this authorization and agreement, you understand that the dentist’s fees are set by Northwood Dental and are not bound by the usual and customary fees of your insurance carrier. You understand that your dental care insurance carrier or payor of your dental benefits may pay less than the actual bill for services. By signing this agreement you revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid in whole or in part by your dental care payor.