| Alliance Family Dentistry |

Alliance Family Dentistry, P.C.

PAYMENT FOR TREATMENT: Payment in full, or patient’s co-payment for those with dental insurance, is due at the time treatment is rendered by one of the following methods (please initial your preferred method):

_____ A. We gladly accept cash or a local check. A service fee of $25.00 will be added to the patient’s account balance for any check returned for non-payment.

_____ B. We accept a bank debit card, Master or Visa Credit Card.

_____ C. If you desire to extend your account payments over time, we offer financing plans to meet your needs, such as Capital One’s Dental Fee Plan offering 3, 6, and 12 month no-interest revolving payment plans W.A.C. and a low interest payment plan for up to 48 months W.A.C.

DENTAL INSURANCE PLANS: Dental insurance is more aptly considered a financial assistance plan. Benefits are a contract between you, your employer, and your insurance carrier. As a courtesy to our patients, Alliance Family Dentistry, P.C., will gladly file insurance claims with “Assignment of Benefits” authorized by the patient/guardian on the form below. It is the responsibility of the patient to provide accurate insurance policy and account information, and, further, it is the responsibility of the patient to follow-up with any insurance carrier for denied claims or claim amounts not paid. If you have dual insurance coverage from your employer(s), by a spouse, or if your insurance carrier should change, please inform us, prior to receiving treatment.

MPA (Maximum Plan Allowance) : This term is used by most insurance companies that pay dental benefits according to a percentage of their plan’s schedule according to your employer’s contract, rather than that of the treating dentist. Any difference between the amount that your insurance carrier pays and Alliance Family Dentistry, P.C., fees will be the responsibility of the patient/guardian and must be paid at time of treatment. If this could be of concern to you, please check with our financial coordinator prior to receiving any dental treatment by Alliance Family Dentistry, P.C.

PATIENT ACCOUNTS: To keep dental treatment costs as affordable as possible Alliance Family Dentistry, P.C., will not routinely carry balances on patient accounts. (See payment methods and MPA section above.) This reduces office overhead and costs for bookkeeping, printing statements, postage and collection of delinquent accounts. All outstanding account balances are due immediately, unless prior arrangements have been made for one of the convenient third party payment plans.

COLLECTION OF DELINQUENT ACCOUNTS: Should any patient account become past due, 60 days from date of service, the account balance will be subject to actions by a collection agency. The patient agrees to pay all costs and reasonable attorney’s fees necessary for collection of this debt.

CANCELLATION OR FAILED APPOINTMENTS: Occasional rescheduling or cancellation of appointments may be necessary due to emergency or unforeseen events. However, we treat each appointment as your personal reservation with the treating dentist and staff member(s) and we will do everything within our ability to seat you as promptly as possible at your appointed time. Appointments cancelled with less than 24 hours notice will be subject to a $25.00 per appointment hour short-notice fee. All failed appointments will be subject to a $25.00 fee per appoinment hour.

Assignment of Benefits

I hereby authorize payment from my insurance carrier directly to Alliance Family Dentistry, P.C., and I further hereby agree to be personally and fully responsible for payment of my account as per the above conditions.

Signature: _____________________________________ Date: ________________

I further state and agree that a photocopy of this document shall be considered as effective and valid as the original for all parts of this contract.

Signature: _____________________________________ Date: ________________

(revised 05/06)



				Financial Policy Alliance Family Dentistry, P.C. PAYMENT FOR TREATMENT: Payment in full, or patient’s co-payment for those with dental insurance, is due at the time treatment is rendered by one of the following methods (please initial your preferred method): _____ A. We gladly accept cash or a local check. A service fee of $25.00 will be added to the patient’s account balance for any check returned for non-payment. _____ B. We accept a bank debit card, Master or Visa Credit Card. _____ C. If you desire to extend your account payments over time, we offer financing plans to meet your needs, such as Capital One’s Dental Fee Plan offering 3, 6, and 12 month no-interest revolving payment plans W.A.C. and a low interest payment plan for up to 48 months W.A.C. DENTAL INSURANCE PLANS: Dental insurance is more aptly considered a financial assistance plan. Benefits are a contract between you, your employer, and your insurance carrier. As a courtesy to our patients, Alliance Family Dentistry, P.C., will gladly file insurance claims with “Assignment of Benefits” authorized by the patient/guardian on the form below. It is the responsibility of the patient to provide accurate insurance policy and account information, and, further, it is the responsibility of the patient to follow-up with any insurance carrier for denied claims or claim amounts not paid. If you have dual insurance coverage from your employer(s), by a spouse, or if your insurance carrier should change, please inform us, prior to receiving treatment. MPA (Maximum Plan Allowance) : This term is used by most insurance companies that pay dental benefits according to a percentage of their plan’s schedule according to your employer’s contract, rather than that of the treating dentist. Any difference between the amount that your insurance carrier pays and Alliance Family Dentistry, P.C., fees will be the responsibility of the patient/guardian and must be paid at time of treatment. If this could be of concern to you, please check with our financial coordinator prior to receiving any dental treatment by Alliance Family Dentistry, P.C. PATIENT ACCOUNTS: To keep dental treatment costs as affordable as possible Alliance Family Dentistry, P.C., will not routinely carry balances on patient accounts. (See payment methods and MPA section above.) This reduces office overhead and costs for bookkeeping, printing statements, postage and collection of delinquent accounts. All outstanding account balances are due immediately, unless prior arrangements have been made for one of the convenient third party payment plans. COLLECTION OF DELINQUENT ACCOUNTS: Should any patient account become past due, 60 days from date of service, the account balance will be subject to actions by a collection agency. The patient agrees to pay all costs and reasonable attorney’s fees necessary for collection of this debt. CANCELLATION OR FAILED APPOINTMENTS: Occasional rescheduling or cancellation of appointments may be necessary due to emergency or unforeseen events. However, we treat each appointment as your personal reservation with the treating dentist and staff member(s) and we will do everything within our ability to seat you as promptly as possible at your appointed time. Appointments cancelled with less than 24 hours notice will be subject to a $25.00 per appointment hour short-notice fee. All failed appointments will be subject to a $25.00 fee per appoinment hour. Assignment of Benefits I hereby authorize payment from my insurance carrier directly to Alliance Family Dentistry, P.C., and I further hereby agree to be personally and fully responsible for payment of my account as per the above conditions. Signature: _____________________________________ Date: ________________ I further state and agree that a photocopy of this document shall be considered as effective and valid as the original for all parts of this contract. Signature: _____________________________________ Date: ________________ (revised 05/06)

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