Troy R. Walton, D.D.S
Troy R. Walton, D.D.S.
271 N. Springcreek Pkwy, Suite D
Providence, UT84332
Methods of Payment - Please read the following options carefully and choose the method of payment.
□Cash or Check Payment at time of service: If insurance is not participating, a 10% discount will be extended for services paid in full at time of service.
□Credit Card Payment (Visa or MasterCard) at time of service: If insurance is not participating, a 5% discount will be extended for services paid in full at time of service.
□Co-payments and Deductibles at the time of service: Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. Patients are also responsible for knowing what their insurance covers and what providers and network(s) are covered under their dental plan(s). This office will bill the insurance company as a courtesy, will be happy to assist in filling out insurance claims, will assist in making collections from insurance companies and will credit any such collections received to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid in full by any insurance company. A monthly statement showing all charges and payments on your account will be mailed out to the responsible party of the account. Any service provided, but not covered by your insurance company will become your responsibility. If your insurance company has not paid your account in full within 60 days, your account balance must be paid by you without further delay.
□Payment Plan Options: Upon approval, financing programs are available through CareCredit®, including 3 to 12 months interest free. A short application needs to be completed for approval.
□Flex Spending/Cafeteria Plan: We require that you pay at the time of service. We will gladly provide the necessary information for you to submit to you flex spending/cafeteria plan in order for you to receive reimbursement.
Payment Policies
Emergency Dental Services: All emergency dental services or any dental services performed without previous financial arrangements must be paid for in full by cash, check, Visa, or MasterCard at the time services are rendered.
Dental Services with Divorce Involved: This dental office is not party to any divorce. In consideration for the professional services to be rendered to me, or at my request, to my minor child or ward, by the dentist, I agree to pay the fees charged for the dental services provided to the dentist or his/her assignee at the time the services are rendered.
Outstanding Balances: Accounts with outstanding balances require payments. A monthly finance charge of 1 ¾ % each month (21% APR) will be charged to the amount not paid after 30 days, with a minimum charge of $3.00 per month. By signing below, you acknowledge receipt of this financial policy and agreement and you agree to pay collections costs and/or reasonable attorney’s fees if any delinquent balance is referred to an agency or attorney for collection or suit.
Returned Payments: This dental office may charge$25 each time your check or other payments is returned to us for any reason.
Appointment Policies
Your appointment is time that has been reserved especially for you, and we strongly encourage all patients to keep their appointments. This officewill reschedule patients that are more than 15 minutes late or don’t have their Medicaid cards. If you change your appointments, we require at least 24 hour notice to avoid a missed appointment fee of $50, $75 for Saturday appointments.
I, the undersigned, understand the above financial options and have chosen the method of payment that will work best for me. Should your account be turned over for collection, the undersigned agrees to pay all costs to collect the debt, including, but not limited to, interest in the amount of 18% per annum, attorney’s fees, court costs, and collection fees in the amount of 40%, the obligation to pay the collection fees shall be imposed at the time of assignment of the debt to a third party debt collection agency. I authorize the release of financially identifiable information concerning my account, including charges billed, payments made, and interest charges assessed, etc. to the dentist’s collection agency or a collection attorney should collection procedures become necessary. This additional amount is in recognition of the costs associated with the said collection process.
Patient, Parent or GuardianDate
Office Staff Initials and Date: