PATIENT FINANCIAL POLICY FOR DES MOINES DENTAL CENTER

It is our optimal goal to provide you and your family with the highest quality of dental care while maintaining a friendly and relaxing environment. In order to keep our standard of care at a level which best serves your dental needs, we ask you to please observe the following guidelines

OUR FINANCIAL POLICY:

Payment is due at time of treatment. For your convenience, we offer several payment options: WE ACCEPT CASH, CHECKS, OR VISA/MASTERCARD, DISCOVER, AMERICAN EXPRESS. WE OFFER EXTENDED PAYMENT PLAN WITH PRIOR CREDIT APPROVAL.(CARE CREDIT)

REGARDING INSURANCE:

We accept assignment of insurance benefits, however we do require your co-payment and deductibles to be paid at the time of service. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. If your insurance company has not paid your account in full within 60 days, the entire balance will be payable by you. All accounts over 90 days will be subject to a finance charge of 1.0% per month, which is an annual rate of 12%.

USUAL AND CUSTOMARY RATES:

Our practice is 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 your insurance company’s arbitrary determination of usual and customary rates.

MEDIA USAGE:

I hereby permit Des Moines Dental Center to use any and all media forms including, but not limited to, photographs, copy and xrays for use on the Des Moines Dental Center web site.

CANCELLATION POLICY:

There are many times when our patients require urgent or emergency treatment and therefore need an appointment as soon as possible. When patients give the office advance notice of their need to cancel a scheduled appointment, this time can then be allocated to those patients with immediate needs. In this way the office can best serve the needs of ALL patients. Bearing this in mind, our office requires a minimum of 24 hours notice if an appointment must be cancelled. If less than 24 hours notice has been given to cancel an appointment, a $50 fee will be assessed.

All minors must be accompanied by an adult during the entire length of minor’s appointment. (Some exceptions may be allowed after authorization form is signed by parent / legal guardian.)

We at the Des Moines Dental Center look forward to taking care of your oral health needs and welcome you and your family to our team of dental professionals.

I have read the above policies of the Des Moines Dental Center and understand my responsibilities as a patient.

Patient Signature______________________________________Date_______________