Financial Policy

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Financial Policy
Island Dental strives to provide the highest quality in dental care. It is our intent to clearly define your financial options and responsibilities as an Island Dental patient so that we may provide you with that care.
Payments and Payment Options: All services are to be paid in full at or before time of treatment. Island Dental accepts cash, check*, and all major credit cards. Island Dental also provides financing options for qualified Patients. Please ask the front desk personnel for more details.
Delinquent Accounts: A finance charge of 18% will be applied to any unpaid balance exceeding 60 days past due. Balances outstanding more than 90 days may be subject to an additional $50 fee for collections processing.
GE Tax: The state of Hawai`i imposes a General Excise Tax on most types of business activities done within the state, including dental practices. Island Dental, in accordance with Hawai`i state law, forwards this tax to all Patients. This tax is not a Dental Service and may not be covered by Patient’s insurance provider/s.
Patients with Dental Insurance: Island Dental will estimate Patient’s costs to the best of their ability. Please remember that all services furnished are charged directly to the Patient and that the Patient is personally responsible for any remainder portion of said services not reimbursed to Island Dental by their respective insurance provider/s. Island Dental will help prepare the Patient’s insurance forms and/or assist in making collections from insurance companies and will credit any such collections to the Patient’s account. Please be aware, we are only able to process insurance claims if all of the Patient’s information is current and accurate at the time of service, otherwise the Patient must file these claims their self. Island Dental cannot render services on the assumption that charges will be paid by an insurance company at a future date.

To avoid any finance charges, Island Dental strongly recommends keeping a credit card on file. By signing below, Patient agrees to have the following card charged automatically for any unpaid balances.

______________________________ ___________________________ _________

Cardholder Signature Card Number Exp. Date

Sedation Appointments: Island Dental is proud to offer Sedation Dentistry; the comfortable solution to seeing the dentist. Because sedation appointments can be lengthy, Patients are required to prepay twenty (20) percent of the total cost of treatment at or before the time of scheduling. The remaining balance will be due no less than one (1) week before Patient’s sedation appointment.
Missed or Cancelled Appointments: In the event the Patient is unable to make their scheduled appointment, Island Dental requires a minimum of two business days in advance notification. Patients who either cancel or reschedule an appointment without 48 hours notice or fail to show for a scheduled appointment will be charged a $50.00 fee.

A $50.00 deposit may be required to schedule future appointments.

By signing below, Patient agrees to the terms and conditions within.

Patient’s Name (Please Print) Patient’s / Guardian’s Signature (Date)

*All checks returned unfunded are subject to a $25.00 NSF fee.

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