Patient Financial Policy Form

  • Financial Policy

  • PAYMENT:

    Payment is due at the time of service for regular appointments. Payment is due 2 weeks prior for scheduled surgical appointments. We do not accept post-dated checks. We do accept cash, personal checks (current date), major credit cards, debit cards, and third-party financing through Care Credit or Lending Club.

    INSURANCE:

    As a courtesy to our patients, we are happy to file your claims on your behalf. We will make every reasonable effort to collect proposed covered amounts from your insurance company to reimburse our patients for out-of-pocket costs. Deductibles and non-covered amounts for hygiene are due on the date of service. Agreed upon amounts as set in the treatment policy agreement are due on agreed-upon dates prior to treatment. The patient is ultimately responsible for all charges incurred. Insurance companies are required by law to pay within 30 days. After 60 days, any unpaid claims will become the sole responsibility of the patient. At that time outstanding amounts to insurance will be required to be paid in full by the patient. Please be advised, we are not participating providers with any insurance carriers. Our first and only priority is outpatients and the quality of care, not the negotiation of benefits between the insurance company and your employer.

    RETURNED CHECKS:

    All returned checks are subject to a $30.00 returned check fee. After a check has been returned, all future payments will be on a cash or credit card basis.

    DELINQUENT ACCOUNTS:

    Accounts over 90 days past due will be handled by our collection service. The patient agrees to pay ALL collection costs in addition to fees for service.

    CANCELLATIONS:

    It is the philosophy of our office to provide optimal patient care. All patients are seen by appointment only and are scheduled with the dentist or hygienist one patient at a time. This allows us to focus our efforts on caring for and treating our patients to the best of our abilities. Thus, we require a minimum of 48 hours notice for non-surgical and 2 week notice for surgical appointment cancellations and reschedules. This is necessary to allow us adequate time to notify patients who are on a waiting list for the first available appointment. Lack of adequate notice inhibits us from offering an exceptional standard of care to our other patients. A fee of $1000 per hour scheduled may be charged for failed appointments, inadequate notice of cancellation, or rescheduling of an appointment with less than required timeframe notice. We appreciate your cooperation and respect of our efforts.

    I have read the above and I understand and agree to these terms regarding my treatment by Riad Almasri, D.D.S.

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