Financial Agreement
Payment Options
WILLIAM STEHLING DDS FINANCIAL AGREEMENT
Thank you for choosing our office as your dental health care provider. We are committed to providing you with the highest quality lifetime dental care so that you may fully attain optimum oral health. Everyone benefits when office and financial policy arrangements are understood. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Agreement which we require you to read and sign prior to any treatment.
We pride ourselves on being honest and transparent with our patients. Therefore, we provide you with our financial policy to ensure no misunderstandings arise regarding the payment for your dental care. We strongly suggest you read through all of it to avoid any confusion in the future.
REGARDING PAYMENT
We desire to make dental treatment affordable to all our patients. Therefore, we accept the following payment options:
Cash, Check, Visa, Mastercard, and Discover.
Payment for services is due at the time services are rendered unless prior arrangements have been made with the doctor and the financial coordinator.
If dentures, partial dentures, crowns and/or bridges, retainers, mouthguards, or nightguards are to be fabricated by a dental laboratory, a 50% deposit will be required at the time of the first impression. The remaining balance is due at the time the prosthesis is delivered.
Any insurance you provide is an agreement between you and your insurance provider. We are not a party to this agreement. Any estimate of what your insurance may cover is not a guarantee of coverage. We do not accept assignment of benefits from your insurance company. Your insurance company will send payments directly to you.
As a courtesy to you, we will process your insurance claims. We do not file with secondary insurance companies.
We will notify you of any balance either by phone call or by mailing a statement. It is your responsibility to notify us of any change in your contact information in order to receive notifications and avoid collections. Any balance past 90 days will go to collections.
REGARDING APPOINTMENT
Your reserved time in our office is important. We understand that occasionally it may be necessary to change your appointment. We ask you to kindly give us a minimum of 1 business day notice. Without this notice, we are unable to offer treatment to other patients that may have needed our care. There will be a $ 62.00 charge for missed appointments or those cancelled with less than a 24 hour notice.
I agree to the terms outlined above for my relationship with William Stehling DDS
Patient/Guardian Signature_______________________________________________ Date _____________
For your convenience, we accept cash, personal checks, money orders and major credit cards. Payment is expected at the time services are performed. When more extensive dental care is necessary, financial arrangements can be made with our office.
Insurance
As a service to our patients, our practice accepts most dental insurance programs, including non-managed care, indemnity (traditional) and PPO out-of-network. We are not part of any managed care network. Our accounting staff will prepare all the necessary forms for your dental benefits. However, we remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. Our staff will gladly submit a pre-treatment estimate to your insurance company so that you will know what your benefits will be.
The fees charged for services rendered to those who are insured are the usual and customary fees charged to all our patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others delay payment for several months.