Financial Policy
Office and Financial Policy Statement
Welcome! We are here to serve your dental needs and those of your family. After your examination and consultation you may have questions about the proposed treatment. Please discuss your dental needs and concerns with us. An informed patient is a more relaxed patient.
Your dental appointments will be scheduled at a convenient time and date. Should you need to change or cancel your appointment, please contact the office at least 24 hours business day in advance to avoid being charged $75.00 per missed appointment. Occasionally we experience a 10-15 minute delay in our schedule due to a patient’s dental emergency, should you be running late, a 10 minute grace period for hygiene or doctor’s appointment will be permitted before the appointment is considered failed. We do staff and reserve time specifically for you and we make every effort to be on time for our regular scheduled patients.
Payment for care is due at the time services are rendered. Our office accepts cash, checks or, for your convenience, Visa, MasterCard, Discover, American Express and Care Credit. We can offer an alternative payment plan to you and will explainit to you more in details after your examination. We can also assist in obtaining a special (“Care Credit”) dental financing. We are happy to file insurance claims as an additional service to you, crediting insurance payments to your account. All remaining unpaid insurance balances are due in full within 60 days of treatment.
Healthy Teeth-Staying Healthy
Most insurance companies limit the number of prophylaxis (cleaning) to one every six months or twice in any given year. If the dentist should recommend additional prophylaxis, there may be a charge to you. It is the responsibility of the patient to check and be aware of any additional charges prior to treatment.
Patient’s acknowledgement:
As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental care service performed without prior financial arrangements, must be paid for in cash at the time services are performed. I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment of all dental services. I carry insurance, I understand that this office will help prepare my insurance forms to assist in submitting claims to receive benefits from insurance companies and will credit such collections to my account. However, this dental office cannot render services on the assumption that charges will be paid by an insurance company. Assignment of Insurance: I hereby authorize my insurance company to pay benefits directly to my dentist accruing to me under my policy. A service charge of 1.5 % per month (18% per annum) (but in no event more than the maximum rate permissible under state law) will be charged on the unpaid balance on all accounts not paid within 60 days of treatment. I understand that the fee estimate listed for this dental case can only be extended for a period of 60 days from the date of the patient’s examination. In consideration of professional services rendered to me, or at my request, by the Doctor and/or his team, I agree to pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected by me, in writing, within the time for the payment thereof. I agree that a waiver for any breach of any term or condition hereunder shall not constitute a waiver of any further term or condition. I further agree that in the event either this office or I institute any legal proceedings with respect to amounts owed by me for services, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney’s and/or collection fees. I grant my permission to you, or your assigns, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and agree to their content.
Our team will ask you to sign a copy of this financial policy when you register as a new patient. If you have any questions or concerns regarding our fees or your financial arrangements for your dental care, please let us know prior to having your treatment provided.
Thank you!
Richard A. Harder, Jr., D.D.S.
D. Young Pham, D.D.S.
