• Financial Policy

  • Thank you for choosing Brighter Smile for your health care needs. We are committed to providing the very best dental care treatment. We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget. The following is a statement of our financial Policy, which you must read, agree to, and sign prior to treatment. Our Financial Policy applies to all services rendered by our office staff. Dental treatment is an excellent investment in an individual’s medical and psychological care. We are always available to answer your questions or assist you in any way we can.

    Practice payment policy:

    1. Patients/guardians are financially responsible for all charges, regardless of third party.
    2. Full payment is due at the time of services, unless prior insurance billing arrangements have been made.
    3. Patients with insurance will be required to pay all “out-of-pocket” fees at the time of service
    4. We accept : Cash, Check, and all Major credit cards.

    Patient / Guardian Financial Responsibilities:

    1. Provide accurate information: You have a responsibility to provide accurate and complete information about your mailing address, Dental insurance and other billing information. If any information changes- names, address, phone, insurance coverage, etc – you must inform this practice immediately. Insurance denials or billing errors due to patient supplied information will result in the transfer of the account balance to the patients’ immediate financial responsibility.
    2. Self-Pay Patients
      Patients without insurance coverage are expected to pay for the services received in full at the time of service, unless a satisfactory payment agreement has been arranged with our billing manager prior to the services being rendered.
    3. Patient with Private Insurance
      Our Dentists participate with most major insurance companies. We will file claims to your insurance company for payment directly to our practice. For participating insurance plans, the practice will accept payment based on contractual agreements. For plans in which we do not participate(i.e. there is no contractual agreement) the practice will expect full payment from the patient at the time of service. Any coverage or payment dispute is a matter between the insurance policy holder and the insurance company.

    Patient Payment Agreement – I understand that I am financially responsible for all charges regardless of the third-party involvement. I agree to pay any deductibles, co-payment, or service deemed as “non-covered” by my insurance carrier at the time of service. If any portion of the balance due, insurance does not pay on my account in 60 days, the outstanding services will become my responsibility, and charged to the card on file.

    Optional Payment Terms:

    1. Full Pay Cash Discount: We offer a 10% accounting courtesy for all treatment that is paid in full (cash or check) at the time of proposal. We will still file your insurance and payment will go directly to you the patient.
    2. Full Pay DOS Cash Discount:We offer a 5% accounting courtesy when your treatment plan co-pay is paid in full (cash or check) at the time of proposal.
    3. Major Service - Two Payment Option:We offer a two-payment option for Crown, Bridge, and Denture treatment. We ask that you pay one-half of your co-payment at the appointment and the second half 1 month later with credit card on file for auto payment.
    4. Full Pay DOS Cash Discount:We offer a 5% accounting courtesy when your treatment plan co-pay is paid in full (cash or check) at the time of proposal.
    5. Term Loan:By arrangement with Care Credit, Lending Club, and Alphaeon we offer our patients, upon approval, an interest-free term loan (3, 6, 12, or 24 months) with no down payment, no annual fee, and no prepayment penalty. Please ask for an application.

    Broken appointments: A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least a one business day (24-hour) notice to avoid a $75-$150 cancellation fee.

  • Patient / Guardian Signature
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