Founders Park Dentistry

Founders Park Dentistry Financial Policies Agreement


Our Financial Policies

Thank you for choosing Founders Park Dentistry. One of the most important aspects of maintaining a long term relationship is good communication from the beginning. We have found that many people do not have a full understanding of how insurance works. In order to avoid any miscommunications down the road, we wanted to share our financial policy with you now. If you have any questions about our policy or how insurance works please ask our team members at any time.

By signing this document you agree to all policies listed below.

 

  • Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits, please contact your employer or insurance company directly. Dental benefit plans will never pay for the completion of your dental care. It is meant only to assist you.
  • WE WILL BILL YOUR INSURANCE AS A COURTESY. If your insurance does not pay within 30 days, we reserve the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare but is important that you recognize that the insurance you have is a legal contract between you and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
  • Although we can maintain computerized histories of payment by a given insurance company, they do change; therefore, it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most current information we have, but it is ONLY AN ESTIMATE.
  • A specific amount of time is reserved especially for you, and we strongly encourage all patients to keep their appointment. We require at least a 48-HOUR NOTICE TO AVOID A CANCELLATION CHARGE of $50 PER HOUR THAT YOU ARE SCHEDULED.
  • A $25 charge may be incurred on returned checks. In the event that an account is turned over to an outside collection agency for collection, the patient is responsible for all collection/attorney fees incurred by Robert Stark, DDS, PA as a result of non-payment.
  • I hereby authorize the release of any information, including the diagnosis and records of any treatments, x- rays, photographs, or examinations rendered, to my insurance company. I hereby authorize my insurance company to pay directly to Robert Stark, D.D.S PA (DBA Founders Park Dentistry), and any proceeds payable under the terms of my insurance policy. I hereby authorize Dr. Robert Stark to perform dental procedures on me, my minor children, and/or family members.

 

Leave this empty:

Signature arrow
Founders Park Dentistry https://smilenwa.com
Signature Certificate
Document name: Founders Park Dentistry Financial Policies Agreement
lock iconUnique Document ID: 8f1d2109deb805b2a99bd343e194871a9ca2d869
Timestamp Audit
May 18, 2020 9:33 pm CDTFounders Park Dentistry Financial Policies Agreement Uploaded by Robert Stark - [email protected] IP 170.10.179.148, 162.158.74.239