This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using the highest quality materials and technology available in the market today.
We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs.
All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your
insurance policy is an agreement between you, your employer, and the insurance company. Our practice is not a party to that agreement. If payment from your insurance company is not received within 60 days from date of
service, you will be expected to pay the balance in full.
As a courtesy to you, we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our practice by signing the authorization on the Assignment of Benefits Agreement. In order for our practice to file your insurance claim, you must provide us with accurate, updated information.
Your estimated co-payment for treatment, which is the amount not covered by your insurance, is due at the time treatment is provided. Your estimated co-payment may be adjusted after the time of treatment depending upon the final reconciliation of insurance payments. If you are uninsured, full payment for all services is due on the date of service.
Our practice accepts cash, personal checks, MasterCard, Visa, American Express, and Discover. Third party, extended payment financing is available upon request and approval. Returned checks and balances older than 60 days will be subject to collection fees and finance charges.
I hereby authorize payment directly to Wellesley Dental Group for services rendered otherwise payable to me. I authorize release of information required to complete insurance claims.
I have signed to acknowledge that I understand this statement and I have accepted responsibility for all fees incurred for my dental care. I understand that future appointments may be contingent upon my having met my
financial obligations with the office, or having made appropriate arrangements with Wellesley Dental Group in advance.