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As part of our goal to
provide the best quality care & service to our patients – this
document communicates our payment policy.
Patient’s
with insurance – We
will gladly submit a request for payment to your insurance
company for the work that you have had performed. The ESTIMATED
difference between what the insurance company will pay and the
balance that is the PATIENT’S RESPONSIBILITY is to be paid at
the time the service is rendered.
Patient’s
without insurance –
Full payment is expected at the time the services are rendered,
unless prior payment arrangements have been made in writing with
our financial coordinator. Please see “Payment Plans” on page 2
herein.
Discounts
– A 5% senior citizen
discount will be given to all patients 65 and older. A 5%
discount will be given to any self-pay patient who pays his
balance in full on or before his first appointment.
I UNDERSTAND THAT THE
RESPONSIBILITY FOR PAYMENT FOR PROFESSIONAL SERVICES PROVIDED IN
THIS OFFICE FOR MYSELF OR MY DEPENDENTS IS MINE, DUE AND PAYABLE
AT THE TIME SERVICES ARE RENDERED UNLESS WRITTEN AND SIGNED
FINANCIAL ARRANGMENTS HAVE BEEN MADE. IN THE EVENT OF DEFAULT I
PROMISE TO PAY INTEREST ON THE INDEBTEDNESS, TOGETHER WITH ANY
COLLECTION COSTS AND ATTORNEY FEES AS MAY BE REQUIRED TO EFFECT
COLLECTION. ****ALL AMOUNTS 90 DAYS PAST DUE ARE ASSESSED 1.5%
PER MONTH FINANCE CHARGE.****
STINE DENTAL, LLC PAYMENT PLANS
1.
Total Fee Payable
on
or before first appointment with 5% courtesy accounting
reduction (includes cash, checks, money orders, Visa, MasterCard
and Discover).
Total Payment =
5% Accounting Reduction=
Total Due =
2.
Half/Half
–
Half of total fee payable on or before first appointment, with
balance due on or before final appointment. See “qualified
patients” note below.
1st Appointment =
Due Date =
2nd Appointment =
Due Date =
3.
Installment Plan
– For
balances that are $300.00 and over we will divide the payments
into 4 equal installments payable over a 90 day period starting
on the initial date of treatment. A 1.5% per month finance
charge will apply. A valid Credit Card imprint or set of
post-dated checks is necessary with this plan. Debit cards are
not acceptable. See “qualified patients” note below.
1st Appointment =
Due Date =
30 Days =
Due Date =
60 Days =
Due Date =
90 Days
= Due Date
=
4.
Care Credit–
This
program is designed to help finance your dental needs. The
program offers you immediate access to credit for your dental
needs. It is designed to take care of the entire family’s
healthcare expenses. You have the luxury of choosing a payment
plan that meets your needs. There are no hidden charges or
fees. Once approved, qualified patients can charge their dental
care right away. You will then receive monthly statements from
Care Credit and your monthly payment will be sent directly to
them. Ask to speak to our financial coordinators regarding an
application. You can also read more about this program on line
at www.carecredit.com .
**Subject to credit approval.
“Qualified Patients” – A
patient qualifies for credit extended internally through our
office, once they have been approved under a Care Credit
application. We will assist the patient in completing the Care
Credit application. If approved, the patient then has the
option of using the program offered through Care Credit or
utilizing our internal financing options. If denied credit with
Care Credit, the patient will not qualify to utilize our
internal financing options. |
