Financial Agreement At Got Smile Dental

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Date conversion17.11.2016
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Financial Agreement

At Got Smile Dental, we believe that you deserve the best care. That’s why we always present you with the best dental solution possible to treat your personal situation. Each year we provide outstanding dental care to thousands of patients. Some have dental benefits but some don’t. If you have dental benefits, here are some important things you should know.

Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits please contact your employer or insurance company directly. Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you.
We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or require our office to accept a reduced fee for service). This means that we work with literally thousands of companies. Although we can maintain computerized histories of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your exact insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment. This does delay treatment but will give you the exact out of pocket figures you may require, although it is not a guarantee of payment.
Many people receive notification from their insurance company that dental fees are “above usual and customary.” An insurance company determines their reimbursement level by surveying a geographical area, calculating the average fee, and then determines that 80% of the average fee is customary. Included in this survey are discounted dental clinics and managed care facilities, which have severely reduced dental fees that bring down the average. Any doctor in private practice will have fees that insurance companies define as “higher than usual and customary.”
We bill your insurance as a courtesy. If insurance does not pay within 90 days, Got Smile Dental reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
Got Smile Dental does require payment in full for your portion at the time of service. We accept MasterCard, Visa, Discover, cash, and checks (for existing patients with an established history). If you are in need of an extended finance option, we also work with Care Credit, who offers a six month “same as cash” or longer terms with an interest bearing revolving charge designed to meet your treatment plan needs on approved credit. Just ask one of front desk staff for more information or an application, or apply online.
After hours/Weekend Emergencies: In the event of an emergency after regular business hours a $145 emergency fee will be charged for established patients in addition to the necessary treatment fees.
We welcome you to our family and look forward to helping you get the healthy, beautiful smile you’ve always wanted. If there is anything we can do to make your visits here more pleasant, please don’t hesitate to ask one of us!

Please sign below to acknowledge acceptance of this agreement.
Patient name: ___________________________________
Signature: ______________________________________
Date: _________________________________________

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