We would like to thank you for allowing us the privilege of being your dental health provider. We are committed to providing you with the best possible dental care. The following is a statement of our office policies regarding the Financial Policy, Missed Appointments, and Cancellations.

Our Dental Billing Process

Thank you for choosing Dr. Ford for your dental needs. To better serve you, we would like explain the dental billing process at our office. Once you provide the office with your dental insurance, we call your insurance company and verify your benefits. The information we receive from your insurance company is only an estimation of coverage and not a guarantee. After you have been seen in our office, we will file your claim to the insurance company directly. If the insurance company does not cover the estimated amount in full, you will receive a statement in the mail and be responsible for the remaining account balance.

Fees and Payments

We make every effort to keep down the cost of your dental care. Our office does not extend credit for dental care. We will estimate your co-insurance based on the information obtained from your benefit company. At the time of your treatment, it is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. For services that are not covered by your insurance, we ask that you pay the entire fee the day of your treatment. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charges for any procedure you may require will be given to you upon request.

Dental Insurance

I understand and acknowledge that I am fully and completely responsible for the payment of all costs associated with the services, treatments, procedures and/or diagnostic methods performed and utilized by the dentist and others. I acknowledge that any insurance coverage that I may have is based on a contract between my insurance company and me, my spouse and/or my employer. The dentist is not a party to this contract and the services, treatments, procedures and/or diagnostic methods are provided to me. Therefore, I acknowledge that I am fully responsible for the payment of all sums owed to the dentist for the services, treatments, procedures and/or diagnostic methods provided to me. As a courtesy to me, the dental office will bill my insurance company and I acknowledge that I will remain liable for any and all amounts not paid by the insurance company for any reason (including but not limited to the insurance company declining coverage after initially approving it) or if the insurance company fails for any reason to reimburse the dentist within 30 days after being billed by the dentist. I acknowledge that it is my responsibility to provide the dentist with my current insurance and any changes thereto.

Unpaid Accounts

All returned checks will be subject to a $30 returned check fee. Any account balances that remain unpaid for 60 days from the date of service shall accrue interest at the rate of 1% per month (12% per year). Accounts unpaid over 90 days will be considered delinquent and may be referred to a collection company or attorney. In the event this occurs, I understand that I will be liable for collection costs of $20. Further, in the event any unpaid account balance is referred to an attorney for collection, I agree also to be responsible for all costs and reasonable attorney’s fees incurred in connection therewith. On accounts past due more than 90 days, no services will be rendered by this office until the balance is paid in full.

Missed Appointments/Late Cancellations

We ask that you call our office and kindly give us at least 48 hours notice to reschedule your appointments. Appointments that are cancelled with less than 24 hrs notice are considered a Broken Appointment and may be subject to a cancellation fee of $55 per hour. We make every effort to remind you of your appointment ahead of time. We understand that last minute changes in your schedule may be unavoidable and we will try to accommodate those changes as best we can. Please understand that when we make an appointment we are setting aside enough time to do our best work and that each appointment is for only one patient. We do not overbook expecting some of our patients to not show for their appointments. Therefore, a broken appointment without adequate notice results in wasted time for us, adding to the cost of providing care for all of our patients.

General Consent

I voluntarily and knowingly request and consent to the services, treatments and/or procedures recommended by the dentist and to all diagnostic methods deemed appropriate by the dentist which may include, but not be limited to, x-rays, study models, imagery, and other aids. I authorize the dentist to perform all such services, treatments and/or procedures and to utilize all such diagnostic methods. Further, I acknowledge and understand that the dentist may engage the assistance of others in performing such services, treatments and/or procedures and in utilizing such diagnostic methods. I understand that the practice of dentistry is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the services, treatments, procedures and/or diagnostic methods that have been recommended. I also understand that the use of anesthesia carries with it significant risks that have been explained to me. I consent to the dentist’s use and disclosure of my health information to my insurance company or managed care company and any agent thereof. I hereby assign to the dentist all of the insurance and managed care benefits due to me for the services, treatments, procedures and/or diagnostic methods provided to me and I authorize my insurance company and/or managed care company to make payment directly to the dentist for the costs associated therewith. I further consent to be contacted by the dentist, any agent of the dental office, or any collection agency (or agent thereof) or attorney to whom an unpaid account balance has been assigned or referred by mail at any address that I provide to the dental office and/or by facsimile, email or phone number (whether a cell phone or landline) at any facsimile number, email address or phone number (whether a cell phone or landline) that I provide to the dental office or any agent of the dental office. Thank you again for choosing Dr. Ford for your dental needs. We look forward to a long lasting relationship with you. Please read carefully and sign to acknowledge you received the agreement