A scheduled appointment is a commitment of time between you and our doctor/hygienist. When an appointment is missed or cancelled on short notice that time is lost instead of being used by another patient. Our office usually confirms appointments 24 hours in advance. Please advise the office if you need to change your appointment at that time. We reserve the right to charge an office visit fee for appointments missed or cancelled without a 24 hours prior notice. Multiple missed appointments can result in dismissal from the practice.
We are happy to bill your dental insurance carriers, on your behalf at no charge. The benefits that are actually paid by insurance carriers vary widely from carrier to carrier and group to group, and depend primarily on the benefits negotiated and paid for by your employer, union, or other group with the insurance carrier. We can provide you with an approximate estimate of your coverage prior to treatment. However, we cannot guarantee the insurance payment as estimated.
Hence, any treatment rendered to you will be your financial responsibility irrespective of what your insurance pays. With your signature (below) you accept our policy and authorize Jonesboro Family Dental to 1) Bill your insurance carriers on your behalf; 2) release any information regarding treatment at this office to your insurance carrier(s); 3) authorize payment directly to Jonesboro Family Dental, any insurance benefits due to services rendered.
**Please inform the dental assistant if you have had x-rays taken at another dental office in the past five years. Insurance may not cover certain procedures if they have been done in another office. Jonesboro Family Dental is not responsible for any balances left by insurance due to treatment performed in another dental office, or otherwise.
For your convenience, we accept cash, check, and all major credit cards (Visa, MasterCard, American Express, and Discover). Furthermore, our office offers applications for easy to use financing programs, the most popular being CareCredit, which offers up to 18 months interest free** financing with no penalty for early payoff. Financing is subject to application approval.**
Non-payment of services/Collection Policies
By signing below, I understand that any amounts not paid by insurance for any reason are my responsibility to pay. Any past due accounts turned over to a collection agency will be subject to additional collection fees, which are a percentage of my balance due, up to 40%. By signing below, I agree that any collection or servicing agency or agencies retained to collect any money due Jonesboro Family Dental may contact me by telephone or text message at any number given by me or associated with my account, including but not limited to cellular/wireless numbers which may result in my incurring fees for the call or text message. I understand, acknowledge and agree that the collectors may contact me by autodialing devices and through pre-recorded messages, artificial voice message or voice mail messages. I further agree that the collectors may contact me using e-mail at any e-mail address I provide or is otherwise associated with my account.
Notice of Privacy Practices
Our office obeys federal and state law regarding the privacy of your health information. With your signature below you acknowledge the receipt of our office's Notice of Privacy Practices as well as the policies listed above.