Patient: our financial policy at a glance … Insurance

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PATIENT: ___________________________



For those patients who are insured, We want to provide the simplest patient experience possible so while it is not a requirement, as a courtesy to our patients, our business office staff will assist you in filing your insurance claims and obtaining the maximum benefits available to you under the terms of your insurance policy. All you have to do is make sure we are always up to date on your most current insurance information.

Some important concepts to remember about your dental insurance:

  • Dental insurance is a contract between you and your insurance provider.

  • Dental insurance benefits are always subject to review by your carrier.

  • The information that we are given by your insurance carrier is not a guarantee of benefits or

  • Your coverage is limited to the terms of your policy.

  • Your estimated patient portion is due at the time of service. These fees are based on your agreement between you and your insurance company. We will always do our part to get the most up to date information from you insurance carrier when estimating the patient portion that we request at the time of your visit.

No Dental Insurance, No Problem! We offer these payment options:

  • Cash

  • Check

  • Credit card – VISA, MasterCard, American Express, and Discover

  • Debit card

  • Affordable Monthly Payment Plans – From CareCredit®

Receive 10% OFF – Cash or Senior Discount – For Uninsured Patients

  Receive 5% OFF – Card Discount – For Uninsured Patients

  • For uninsured patients (i.e. Patients that do not have dental insurance coverage)

  • Payment is due in full at the time service is performed

  • There are no other outstanding balances

  • When you pay with either a debit or credit card

  • Cannot be combined with other discounts or discounted dental plan programs


Affordable Monthly Payment Plans – From CareCredit®

  • NO interest is available to qualfied patients when paid-in-full within 12 months

  • No up-front costs

  • No pre-payment penalties

  • Want to know more? Ask us how you can sign up !

I, ______________________________ have reviewed and acknowledge the above options for payment listed above. I agree to choose one of the above listed payment options prior to any treatment services being rendered unless another mutually agreed upon arrangement has been secured between myself and Dr. Fillak. Furthermore, I have also been informed that this agreement will be placed in my chart for review at any such time that I request and the complete financial policy is posted in the office Lobby for me to review at any time.

SIGNATURE OF PATIENT OR AUTHORIZED SIGNER : __________________________________________

PRINTED NAME OF SIGNATORY : ____________________________________________________

RELATIONSHIP IF NOT PATIENT: __________________________


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