Patient Agreement and Financial Policy
I hereby agree to be responsible for the costs of care provided by KB Dental and/or the dental team for myself or my dependent(s). These include any deductibles and amounts not covered by insurance. I also understand that it is my responsibility to be aware of any limitations, and benefits of my insurance policy. Payment to this office is my responsibility and I am aware that if the insurance company does not reimburse the doctor within 60 days, I am responsible for the total amount(s ).
I understand that there will be a $35 charge to all accounts in which a check payment is returned.
I understand that because appointments are not double-booked, I must provide notice of cancellation at least 48 hours prior to my scheduled appointment time. For appointments scheduled for 90 minutes or longer, I will be required to make a reservation fee of $100 prior to scheduling the appointment, which will be applied to my out-of-pocket expense for the appointment. This reservation fee is non-refundable. If I do not show up for my appointment or I do not give adequate notice if I am unable to keep my appointment, the reservation fee will be forfeited. For appointments scheduled for less than 90 minutes, a $50 cancellation fee may apply if I do not provide notice of cancellation at least 48 hours prior to my scheduled appointment time.
We make every effort to schedule appointments that are most convenient for you and that fit your personal schedule. Because we do not schedule several patients at the same time, all appointments are reserved exclusively for you. In return, we ask that you make every effort not to change your reserved dental appointment.
I understand that for any treatment less than three hundred dollars ($300) payment in full is due at the time of service. I understand that after 60 days, any unpaid balance will incur a $10 billing fee. I understand that failure to pay amounts due to this office will result in my account being placed with a collection agency. In the event that my account is further referred to an attorney, I agree to pay all collection and attorney fees.