Pacific Family Dentistry

PACIFIC FAMILY DENTISTRY

Hyun Min Lee, DDS PC

10029 SW Nimbus Avenue, Suite 220, Beaverton, OR 97008

OFFICE POLICY

In an effort to keep administrative costs down while maintaining a high level of professional care, we have established the following payment policy for our patients. Our primary goal is to help our patients experience good oral health. We wish to spend our time and energy toward that end and avoid any financial misunderstanding.

FINANCIAL RESPONSIBILITY

PAYMENT FOR TREATMENT RENDERED AT TIME OF SERVICE

For your convenience we have made arrangements to accept VISA/MasterCard, American Express, and Discover. Checks and Cash are also accepted.

EXTENDED PAYMENT PLANS

We are unable to offer extended payment plans within our office. We do work with CARECREDIT. This company offers many different payment options. CARECREDIT offers no interest payment plans; convenient low monthly payment plans are also available with no annual fees or pre-payment penalties. If you are interested in looking into this further, please let us know.We have brochures and applications available. CARECREDIT may be contacted directly at 1 800 365 8295 or online at:

DENTAL INSURANCE

We accept most dental plans and, as a courtesy, we will bill your insurance carrier for you with benefits assigned to be sent to our office.

We always make every effort to ESTIMATEyour out of pocket portion as accurately as possible. This ESTIMATED portion is all we ask that you pay at the time of service.

Remember every insurance plan is a contract between your employer and the insurance company. Our office is outside of this contractual agreement and we are not always given full information about the limitations and exclusions of your specific contract. Employers may change contracts at any time without notifying employees. With that said,it is not always possible to get every detail of each plan updated for all patient visits. We cannotguarantee that ESTIMATES given will be exact, and at times this will result in a difference between the ESTIMATED portion and the actual INSURANCE BENEFIT received.

We strongly advise your participation in reviewing your specific individual plan benefits and frequency limitations. We can work together to make sure you receive the dental benefits available to you.

I understand that Pacific Family Dentistry employees cannot guarantee the amount of insurance benefit I may or may not receive from my insurance policy. I authorize payment to be made directly to Pacific Family Dentistry. INITIAL ______

PAST DUE BALANCES

Balances exceeding 60days will be charged a fee of 1.5%per month which is equivalent to 18% per year with a minimum of $5.00.

FAILED APPOINTMENTS

A fee of $50.00 (per half hour) may be charged for appointments cancelled or broken without 24 hours notice. When you schedule an appointment, you are reserving our office and professional staff for your treatment needs.

NSF/RETURNED CHECKS

A fee of $25.00 will be charged for checks returned.

I have read and understand this entire policy. I understand that regardless of any insurance coverage I may or may not have, I am responsible for the payment of my entire account balance. I agree to pay any fees applied to my account for broken appointments. I agree that in the event costs and/or fees are incurred in connection with the collection of my account, I will pay all such fees including collection costs, attorney’s fees, and all court costs.

Responsible party printed: ______Patient name printed: ______

(If different from responsible party)

______Date: ______

Signature (Responsible party)