Levine Dental Financial & Appointment Policies
We are committed to providing you with the best possible dental care.
We will assist you in obtaining a superlative level of oral health. If you have insurance we will help you receive the maximum allowable benefits from your insurance company. In order to do this, we will need your assistance and understanding of our policies. You must remember, however, that it is your insurance. It is a contract between your employer and the insurance company and we are not a party to that contract. The patient is still responsible for the full fee of their treatment regardless of insurance payment or not. We will gladly discuss your treatment and answer any questions you might have as to the involvement of your dental benefit (insurance) program.
Please read and understand the office financial policies listed below and sign at the bottom to signify that you understand these policies:
- Whenever possible, before treatment even starts, we will give you a printout of your proposed treatment and estimated reimbursement from your dental benefit company. After each visit you will be given a printout of what treatment you had completed during that visit along with your estimated patient portion and estimate dental benefit. ALL PAYMENTS ARE DUE AT THAT TIME unless other arrangements have been made.
- Any account for whatever reason that has a balance over 60 days will be subject to a rebilling charge of 1.5% per month (an annual rate of 18%).
- Accounts with arrangements that have not been kept will be charged a service charge of $5.00 per month.
- We accept MasterCard, Visa, American ExpressDiscover, CareCredit, checks and cash.
- Returned checks will be subject to a fee of $45.oo to cover charges we incur due to it. They will also be subjected to additional fees that may be charged by an outside collection agency or attorney if it needs to be turned over for collection.
- Any account referred to a collection agency/attorney will be responsible for any and all fees associated with collecting the account.
- I understand that all services rendered me, my dependents or others assigned by me to my account are charged directly to me. I further understand that I am responsible for payment.
- If I have insurance, I undrstnad that I am still the one responsible for all fees charged.
- If for some reason I can’t make my appointment, Levine Dental Associates requires 48 hours notice. If for some reason this does not occur, I will be charged $75.00 for each 30 minutes of appointment time.
- Continually changing appointments prior to the 48 hour period may result in a patient being appointed only during specific time frames reserved for those cases.
- Our office calls to cinfirm appointment times and see if there are any last minute questions or concerns. It is the responsibility of our patients to return these calls and verify their appointment times and to provide us with as many phone numbers as possibe to reach the appointment.
- I UNDERSTAND THAT I AM ULTIMATELY RESPONSIBLE FOR THE ENTIRE BALANCE OF MY ACCOUNT FOR ANY PROFESSIONAL SERVICES RENDERED AS WELL AS ANY CHARGES OUTLINED ABOVE. I ALSO UNDERSTAND IT IS MY RESPONSIBILITY TO KEEP APPOINTMENTS I HAVE MADE.