Kravitz and Miller Dental P.C.
890 Poplar Church Rd Ste. 404
Camp Hill, PA 17011
(717) 761-2453
Financial Policy
Welcome to our practice and thank you for choosing Drs. Kravitz, Miller, and Robertson as your dental care providers. We are committed to providing you with the best possible care and would be happy to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your financial responsibility.
Your insurance policy is a contract between you and your insurance company. We will submit claims to your insurance carrier for the treatment needed and received as a courtesy to you our patient. It is your responsibility to verify your insurance coverage and eligibility on or before the date(s) of service. Otherwise, you are responsible for payment on that date of service. We will not become involved in any disputes between you and you insurance company regarding deductibles, coinsurances, covered charges, secondary insurances, “usual and customary” charges, etc. other than to supply necessary factual information. If you have a secondary insurance plan please make sure which plan is the primary and which is the secondary for your care. It is your responsibility to provide our staff with accurate insurance information so a claim may be correctly submitted. You are also responsible for prompt payment of your account. If no payment is received from your insurance company within 90 days the balance on the account then becomes your responsibility. Please be aware that some or all of the services provided to you may be “non-covered” services or exclusions according to your insurance policy. Therefore, you are responsible for payment in full for these services. At the time of service you may be responsible for payment of coinsurances, deductibles, and non-covered services. If you do not have insurance we expect payment in full at the time of service unless other payment arrangements have been made. We accept cash, check, Discover, Visa, MasterCard, and American Express. We also offer financing through CareCredit and AmeriChoice. There will be a fee of $25.00 assessed for any returned checks.
Missed Appointments— It is your responsibility to keep your scheduled appointment. As a courtesy to our patients we do make reminder calls approximately 2-3 days prior to your scheduled visit. It is important that you listen to the entire message and call us back to confirm that you will or will not keep your appointment. Also, it is your responsibility to make sure that we have the correct contact information. Please make sure to update address, phone numbers (including cell. number), etc. at every appointment. We require at least a 24 hour cancellation notice on all appointments. There will be a missed appointment fee of at least $40.00 charged to your account for each appointment not cancelled within 24 hours. After three or more “no-show” appointments, the patient may be dismissed from the practice.
I understand that I am financially responsible for all charges whether or not paid by my insurance company. I understand that a monthly service fee of $5.00 will be added to my account if my balance is not paid within 30 days. I understand that my account will be turned over to a Collection Agency after 90 days of delinquency and that a 30% collection fee will be added to the balance, which I am responsible for paying. If my account is in Collections, I may be required to pay the balance (including any fees) in full before treatment is resumed. I also understand that if I do not abide by these terms, I may be given a 30 day notice of dismissal from the practice.
Patient/Responsible Party Signature______Date______