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Thank you for choosing us as your healthcare provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our financial policy which we require you read and sign.
As a condition of treatment by this office, financial arrangements must be made in advance. Financial responsibility on the part of each patient must be determined before treatment.
Patients who carry dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies, and will credit any collection from insurance to the patient's account. This dental office cannot render services on the assumption that the resulting charges will be covered by insurance, and there is no guarantee patient's insurance will cover the services we recommend.
We will gladly file your insurance claim, however, we do require all co-payments and deductibles to be paid at the time of service. The balance is your responsibility. Please keep in mind, not all services are a covered benefit of all plans, and that your insurance coverage is an agreement between you and your insurance company. If you do not understand your coverage, please contact your insurance carrier or, if your coverage is provided through your employer, contact your benefits administrator at your employer. If your insurance company has not paid your account in full within 45 days, the balance will be bill to you.
For those who do not have dental insurance, if you choose to pay in full on the date the services are provided by cash or check only, you will receive a 5% discount. York Family Dentistry is not a lending institution and due to the nature of lending laws, accounts must be paid within 1-3 billing cycles (within 90 days). If you are unable to pay your account in full by cash, check, money order, Visa, MasterCard, or Discover within 30 days, you must contact our office (402-362-1339) to discuss billing payment options.
A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
Any account balance over 120 days old must be paid before any household member can receive further services at York Family Dentistry. In the event of non-payment of your account, we do use an outside agency as a means of collection should we deem necessary.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time of services are performed unless other arrangements are made.
After hours emergencies: If it is deemed necessary for after hours care (outside of our normal office hours), there will be a minimum charge of $150.00 (due at the time of emergency) and the normal office fees for the procedure.
Missed appointments: Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $35.00.
I understand that any fee estimate for this dental care can only be extended for a period of six months from the date of the patient examination.
In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
