 |
(989)
872-3870
6240
Hill Street
Cass City, MI 48726
E-mail us
for more
information
© 2003
James D. Thomas, DDS, PC
all rights reserved |
 |
The
text of the policy is below. You may download the form in Adobe
Acrobat PDF format by clicking on the image to the right. You may
then print, sign and bring the form to our office. 
To view and print the document, you'll need Adobe Acrobat Reader
on your computer. You may click on the Acrobat logo button to download
the software.
Our Financial Policy
Dr.
James D. Thomas & Dr. R. Paul Chappel
Thank you
for choosing us as your dental health care provider. Our main
concern is that you receive the proper and optimal treatments
needed to improve and maintain your oral health. To avoid any
possible misunderstandings regarding payments for services
rendered,
we are providing you with this statement of our financial policy.
If you have any questions or concerns about our payment policies,
please do not hesitate to ask our office staff.
Payment is due at the time the services are rendered. We accept
cash, checks, and for your convenience, most major credit cards.
We can also make available an application for one of our patient
financing companies, should you desire. We will be happy to process
your insurance claims at no additional charge. You may be required
by your insurance company to bring a signed insurance form to
each visit. We do accept assignment of insurance benefits. However,
please understand that:
- Your
insurance policy is a contract between you, your employer
and the insurance company. We are NOT a party to that contract.
Our relationship is with you, not your insurance company.
- All charges
are your responsibility, whether your insurance company
pays or not. Not all services are a covered benefit in
all contracts. Some insurance companies arbitrarily select
certain services they will not cover. Please understand that
our patients
have hundreds of different policies and it is impossible
to keep abreast of everyone’s changes and coverage. We will do
our best to assist you.
- Fees for
these services, along with unpaid deductibles and co-payments
are due at the time of treatment. We estimate these
payments for you, given all the information we have available.
All information you can provide us will help to estimate
more accurately.
- If the
insurance company does not pay in full within 90 days, we
may ask you to pay your balance due with cash, check or credit
card.
- Returned
checks will be subject to additional collection fees.
- Account
balances older than 30 days will be subject to finance
charges of 1½ % per month, which will be added to your
account. Balances older than 90 days will be subject to collection
proceedings and the associated costs will be charged to the patient.
- If your
account is over 90 days past due, we will not schedule any
appointments until the account is brought current. We will
see you on an emergency basis only.
- Fees
quoted for services will be honored for 30 days, but may
change after that.
- Parents
or guardians that accompany minor children are responsible
for the charges incurred that day.
We understand that temporary financial problems may affect the
timely payment of your balance. We encourage you to communicate
any such problems so that we can assist you in the management
of your account.
I have read and understand the financial policy.
___________________________________________
Patient’s
Signature (Guardian, if patient is a minor)
_______________________
Date
|
 |
