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Financial Policy and Dental Insurance PDF  | Print |
Steven B. Andreaus, D.D.S., P.A.
Five Points Center for Aesthetic Dentistry
1637 Glenwood Avenue
Raleigh, N.C. 27608


OUR FINANCIAL POLICY

Payment is due at time of service unless you are approved for a Payment Plan Any insurance payments will go directly to you.

Thank you for choosing us as your dental health care provider. We are committed to giving you exceptional dental treatment. Please read Our Financial Policy carefully and sign below.

Our Financial Options are as follows:

  1. Cash or Check ($40 returned check charge)
  2. MasterCard, VISA, or Discover
  3. 90 days interest free for treatments exceeding $1,500
  4. Care Credit for patients desiring more than 90 days to pay for treatment

5% Discount for payment in full by cash or check prior to treatment for services exceeding $1,500.  We are unable to offer 5% discount for credit card payment or extended payment plans.

Insurance
Our office understands the value of insurance benefits to our patients. We will file your insurance as a courtesy to you and supply all documentation to assure your maximum benefits. There are no guarantees, however, and the insurance relationship is between the insurance company and the insured. Payment for dental services is the responsibility of the patient.

Usual and Customary Rates
Our practice in committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.

Missed Appointments
Appointments are valuable blocks of time. When an appointment is broken or cancelled on short notice (less than 48 hours) it prevents us from helping someone else. Wasted appointment time also results in higher health care fees. In order to control dental costs for all our patients, we must charge a non-refundable $40.00 cancellation fee for all appointments that are cancelled with less than 48-business-hours notification (Monday – Thursday). As a courtesy to our patients, we make every effort to call two days in advance to remind you of your appointment. Please help us control costs as well as serve you better by keeping all scheduled appointments.

I have read and understand the financial policy for this office:

Printed Name: _______________________________________
Signed: _____________________________________________
Date: _______________________________________________

Patient Name if Minor or other than above: ________________

 


 

 

Steven B. Andreaus, D.D.S., P.A.

Five Points Center for Aesthetic Dentistry

1637 Glenwood Avenue

Raleigh, N.C.  27608

 

OUR FINANCIAL POLICY

Payment is due at time of service unless you are approved for a Payment Plan

Any insurance payments will go directly to you

 

Thank you for choosing us as your dental health care provider.  We are committed to giving you exceptional dental treatment. Please read Our Financial Policy carefully and sign below.

 

Text Box: Our Financial Options are as follows: 1. Cash or Check ($40 returned check charge) 2. MasterCard, VISA, or Discover 3. 90 days interest free for treatments exceeding $1,500 4. Care Credit for patients desiring more than 90 days to pay for treatment 5% Discount for payment in full by cash or check prior to treatment for services exceeding $1,500. We are unable to offer 5% discount for credit card payment or extended payment plans. 

 

 

 

 

 

 

 

 

 


Insurance

Our office understands the value of insurance benefits to our patients.  We will file your insurance as a courtesy to you and supply all documentation to assure your maximum benefits.  There are no guarantees, however, and the insurance relationship is between the insurance company and the insured.  Payment for dental services is the responsibility of the patient.

 

Usual and Customary Rates

Our practice in committed to providing the best treatment for our patients and we charge what is usual and customary for our area.  You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

 

Missed Appointments

Appointments are valuable blocks of time.  When an appointment is broken or cancelled on short notice (less than 48 hours) it prevents us from helping someone else.  Wasted appointment time also results in higher health care fees.  In order to control dental costs for all our patients, we must charge a non-refundable $40.00 cancellation fee for all appointments that are cancelled with less than 48-business-hours notification (Monday – Thursday).  As a courtesy to our patients, we make every effort to call two days in advance to remind you of your appointment.  Please help us control costs as well as serve you better by keeping all scheduled appointments.

 

 

This copy is for patient’s records.

Patient signed separate document acknowledging receipt of this document.
 
Copyright © 2013 Five Points Center for Aesthetic Dentistry. All Rights Reserved.