Financial Policy
Thank you for choosing our practice as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read, and sign prior to treatment. All patients must complete our Information and Insurance form before seeing the doctor.
FULL PAYMENT IS DUE AT TIME OF SERVICE. IF YOU HAVE INSURANCE - YOUR ESTIMATED PORTION IS DUE AT TIME OF SERVICE UNLESS PRIOR ARRANGEMENTS WERE MADE WITH OUR OFFICE. WE ACCEPT CASH, CHECKS, MONEY ORDERS, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER, SUNBIT and CARE CREDIT.
REGARDING INSURANCE ESTIMATES/COPAYS:
Fees are estimates only, are valid for 30 days from the date shown above and are subject to revision. Treatment could be altered if your dental needs change or coverage changes. The patient will be notified of any change(s) in treatment. Our office team will verify your coverage with your dental plan (if applicable) as a courtesy and part of your treatment with our office. The contract with your dental plan is your responsibility to understand and follow as per your needs. All claims are subject to review and under the provisions of your plan coverage at the time the claim is received and reviewed by your insurance company. This is not a guarantee of coverage. Please refer to your member handbook for your dental coverage or contact your plan directly if you have questions about your coverage and/or limitations.
REGARDING INSURANCE PLANS WHERE WE ARE A PARTICIPATING PROVIDER:
All ESTIMATED portion and deductibles are due prior to treatment. In the event that your insurance coverage changes to a plan where we are non-participating providers, refer to above paragraph.
USUAL AND CUSTOMARY RATES:
Our practice is committed in providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
ADULT PATIENTS:
Adult patients are responsible for full payment at time of service. Estimated Co-payments in conjunction with insurance (if applicable) will be collected at the time of service.
MINOR PATIENTS:
The adult accompanying a minor and the parents (or guardians of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to be approved; Visa/MasterCard/American Express/Discover, or payment by cash or check at time of service has been verified.
MISSED AND CANCELLED APPOINTMENTS:
Our goal is to provide quality care to all of our patients promptly. However, No-shows, late arrivals, and cancellations inconvenience our providers and our other patients. Please be aware of our policy regarding missed and canceled appointments. If cancellation is necessary, we require that you call at least 4-hours in advance. Failure to do so you will be subject to a $50 cancellation/no-show fee. If you fail to provide a 4-hour notice for a second time, a $50 cancellation fee and a $50 non-refundable retainer fee must be paid to be reappointed. The $50 retainer will be applied to services rendered on your new scheduled date. If no balance is due after service rendered the $50 retainer will be refunded. Failure to adhere to the cancellation/no-show policy you forfeit your $50 retainer fee. Our team will make several attempts to confirm your appointment leading to your appointment day. Confirmation is required to ensure your appointment time is held for you. Failure to confirm your appointment 24 hours in advance is subject to cancellation.
INTEREST:
We reserve the right to charge interest in the amount of 18% per annum (1.5% monthly) as provided by state law. Any account balances transferred to our Collection agency will assess additional fees for transfer and applicable interest charges for delinquent balances.
Thank you for understanding the Financial Policy.
Supplemental Charges Policy
Oftentimes, root canal treatment involves additional secondary procedures that may be required by the referring general dentist or needed by the endodontist (specialist) to provide the best care and ensure a successful treatment outcome. Insurance oftentimes will not cover these charges. Your endodontist will discuss the need for these procedures and attain verbal consent prior to the treatment. These charges do not apply to all treatments but may be needed for your tooth. They include (CDT code):
Post Space (D3950) $135
Post Removal (2955) $150
Internal Perforation Repair (3333) $225
Treatment of canal obstruction (3331) $116
Non-restorable; Incomplete Endo Therapy; Fracture (3332) $235
RCT Endodontics will make every effort to bill to insurance for these procedures and if the insurance covers all or a portion of the charges a refund will be administered. Please ask any questions about these charges with the endodontist. It is your right to decline these treatments.
Credit Card Authorization
I hereby authorize RCT Endodontics, LLC to submit claims to my dental insurance plan on my behalf and agree to assign the payment directly to RCT Endodontics, LLC. I understand that my dental insurance plan is an agreement between my insurance company and myself. I further understand that I am responsible for any service fees or balances that may not be covered by my dental insurance plan and any differences resulting from the amount billed, including estimated co-payments already collected, and the amount covered by my plan. I authorize RCT Endodontics, LLC to debit my credit card account for payment of any account balance remaining once the insurance check is posted to my account. I authorize RCT Endodontics to charge my credit card for agreed upon Endodontic services, for balances owed not to exceed $150.00. I understand that my information will be saved to file for future transactions on my account. I understand that my card may be charged up to 6 months after my claim is paid for any balance left on my account that is $150 or less for all visits and treatment rendered within this 6 month period. I certify that this is my credit card and that I am legally authorized to give permission for its use. By signing this agreement and by photocopying and/or saving my credit card, I hereby give my fully informed consent to treat the above-named patient and I agree to allow RCT Endodontics, LLC to debit my credit card for charges incurred.
I understand and agree to this Financial Policy and with my signature I acknowledge the receipt and/or offering of RCT Endodontics, LLC Privacy Practices Notice provided by the office. I understand that I am not obligated to take the form if I choose to.