Financial Agreement
Initial All co-pays and out of pocket estimates are due at the time of service. Initial All claims to insurance will be filed for you by Starting Point Dental Services, any balance due after insurance payment becomes the patient’s responsibility.Initial Starting Point Dental Services, will communicate with you by email and paper statement if there is an open balance on your account.A complete breakdown of our financial processes is included in your new patient folder and can be requested anytime at the front desk. We will do our very best to collect all the insurance benefit that you have available and we will always communicate with you prior to running your card on file. If we reach out to you about a balance, it is important that you call us back as soon as possible if you have questions or need to make an arrangement for payments.
Credit Card Agreement
Initial I understand that a credit card will be kept on file and processed for any balance that is not covered by insurance and becomes 60 days or older.
OR
Initial I refuse to leave a credit card on file but I understand that any balance on my account that becomes older than 60 days will have a $25 fee added per month and will increase my balance due until the account is settled. The late fees will not be reversed under any circumstance.By my signature below, I acknowledge that I have read and understand the Financial Policy for Starting Point Pediatric Dentistry and Orthodontics.