We expect payment in full at the time of service unless payment arrangements have been previously made with our Treatment Coordinator. For our patients with dental insurance, we are happy to verify and file your insurance to help you receive the full benefits of your coverage. However, we can make no guarantee of any estimated coverage or payment. The insurance policy is an agreement between you and your insurance company; ultimately you will be directly responsible for all charges. Please know that we will do anything possible to see that you receive the full benefits of your policy. Due to restrictions placed by the insurance companies, the doctors of Kirksville Dental Group choose not to be preferred providers for most insurance companies. This means the patient is responsible for any balance the insurance company does not cover.
It has been our experience that it takes three to six weeks to receive payment from most insurance companies. Due to our costs being incurred on the day services are performed, we ask that your deductible and estimated co-pay be paid the day work commences. If your insurance company has not paid in a timely manner, we will ask that payment, in full, be remitted by you and the insurance company can reimburse you directly. If you have a secondary dental insurance we would be happy to file to both insurance companies, however, we are unable to estimate what the second insurance company will pay. Due to this, we will only estimate what your primary insurance company pays and ask for the estimate on the date services are performed. After the secondary insurance pays, Kirksville Dental Group will reimburse any payment received.
Patients with insurance are responsible for obtaining all necessary information prior to their appointment. If we do not have the information required to file the claim, we will ask for full payment at the time of service. All co-payments and deductibles are due when services are rendered.
The Guardian who brings a minor child to our office is responsible for payment, in full, or the estimated patient portion for patients who have dental insurance.
Cash or Check
Credit Cards: We are happy to accept payment by MasterCard, Visa, Discover or American Express.
Finance Company: Through CareCredit, we are able to offer our patients, who qualify, an interest-free line of credit for up to one year. The application process is easy and can be done in the comfort of your own home. Log onto carecredit.com, enter Kirksville Dental Group under “find a Doctor”, locate our name and click Apply Now. The application is simple and you will have the results immediately. Print off the paperwork indicating you have credit through CareCredit which can be used until you receive your card in the mail. The CareCredit credit card may also be used in other locations in the area, including specialist in the outlying communities.
$0-800 6 Months
$800- Over 12 Months
We have a staff member dedicated to insurance billing/financial arrangements. Please feel free to contact her with any questions at 660-665-1901.
Cancellation & Late Policy: Your appointment time is reserved for you. If you are late for your appointment, we may not be able to accommodate you in our schedule. If you think that you will be late, please call as soon as possible so that we may advise you if your late arrival can be accommodated, or if we will need to reschedule the appointment. Missed appointments or short term cancellations (within 24 hours) without proper notification can be costly and unfair to other patients who are in need of appointments. An answering machine is available for messages left after business hours. Repeated missed appointments, of any kind, may be subject to dismissal from our practice.
CONSENT: I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS AND CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY TO PAY MY DENTAL BENEFITS DIRECTLY TO MY DENTAL OFFICE. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered. I further understand that a finance charge will be added to any overdue balance.
Signature (Patient or responsible party) Date