Thank you for choosing Lepore Comprehensive Dentistry as your healthcare dental provider. We are committed to successful treatment performed to the highest standard of care, so that you may fully attain optimum oral health throughout your life. In addition, we will endeavor to make your visit pleasant and comfortable. We have found that a clear agreement regarding financial policy before treatment begins results in a better doctor-patient relationship. Please understand that your bill is considered part of your treatment.
Payment Methods:
- Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa and Discover. We are happy to offer financing through CareCredit and Wells Fargo Financing.
- Please Note: In the case, it becomes necessary for our office to enlist a collection service and/or legal assistance, you will be responsible for any collection and/or legal charges incurred up to $70.00.
Missed/Broken Appointments:
- A missed/broken hygiene (cleaning) appointment within 48 hours will incur a fee of 25% of the value of the visit up to $250 with a minimum of a $50 charge.
- A missed/broken doctor (dental treatment) appointment within 48 hours will incur a fee of 25% of the value of the visit up to $750 with a minimum of a $50 charge.
Insurance:
- As a courtesy to you, we will help you process all your insurance claims. Please understand that we provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly what is estimated. Your insurance company and your plan benefit ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible.
- 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, or with the patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company. Our office is not a party to that contract.
- Our practice is committed to 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.
- We ask that you sign this form and/or any other necessary documents that may be required by your insurance company. This form instructs your insurance company to make payment directly to our office.
- At the time of service, we ask that you pay the deductible and co-payment, which is the estimated amount not covered by your insurance company, by cash, check American Express, MasterCard, Visa, or Discover.
- Insurance Payments are ordinarily received within 30-60 days from the time of filing. If your insurance company has not made payment within 60days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
- We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.
- If you do not wish to have our assistance with your insurance claims, you may choose to pay at the time of service and submit the insurance claim yourself. Talk to our office manager if this is your desire.
- Please understand that insurance is a method of payment, not a method of treatment. While we certainly take your insurance benefits into consideration while formulating a treatment plan, we do not allow ourselves to treatment plan based solely on what your insurance may or may not cover. The need for treatment is diagnosed by doctors irrespective of insurance coverage.
We thank you for the opportunity to serve your dental health needs and welcome any questions you may have concerning your care or our financial policy.
CONSENT: I understand that the responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that finance, re-billing, collection charge, our attorney fee will be added to any overdue balance. I also assign all insurance benefits to the Doctor.