Squaw Peak Dental Financial Policy
Thank you for choosing Squaw Peak Dental for your dental care. Please carefully read and initial by each statement and sign below. This has been put in place to ensure that we do everything we can to satisfy our patients and make them happy to be a part of our practice. We do this by providing superior dental care in a pleasant and safe atmosphere. Communication is the key, it's important that we work together to assure that payment for services is as simple and straightforward as possible. Our front office team would be happy to discuss these policies with you.
I understand that if I do not have my insurance card and/or co-payments, that my appointment may be rescheduled until such a time that I can provide the required documents or payments. We have found that most of our patients would prefer to be informed of their dental investment and be provided the opportunity to take care of their account in a timely fashion.
Yes I Understand
No I Do Not Understand
I understand that Squaw Peak Dental will collect, prior to any procedure, deductibles and coinsurance in full for the planned dental procedure. Coinsurance payments and any balance due are determined by the details of your insurance policy and the agreement between you and your insurance company. Our office will provide written notification of your estimated charges due. Ultimately, it is up to you, the patient, to know your insurance benefits.
Yes I Understand
No I Do Not Understand
I understand that if my account is not paid in full within 90 days, a $35,00 collection processing fee will be added to the outstanding balance and will be turned over to a financial institute for further processing (collection). No additional appointments will be made for delinquent accounts until they are brought current. We reserve the right to ask for a non-refundable pre-payment for any future appointments.
Yes I Understand
No I Do Not Understand
I understand that a $35.00 service fee will be added for any checks returned for any reason and you will be responsible for payment of this fee and the amount of the returned check. NSF checks must be redeemed with certified funds (cashier's check, money order or cash).
Yes I Understand
No I Do Not Understand
I understand that if I am unable to make a scheduled appointment I need to contact Squaw Peak Dental at least 2 business days before my scheduled appointment time. Missed appointments prevent us from scheduling appropriately and keep others in need of dental care from being seen. A fee of $50.00 per half hour will be assessed for all missed appointments not rescheduled with at least a 2 business day advanced notice. Squaw Peak Dental reserves the right to discontinue the provider-patient relationship or ask for payment in full, non-refundable, if a patient misses 3 scheduled appointments.
Yes I Understand
No I Do Not Understand
I understand that I will receive one or all of the following correspondences to confirm my appointments. #1. An email 3 weeks prior to your appointment. #2. An email and/or text 5 days before your appointment (you can confirm by selecting the confirm button on this email.) #3. A courtesy text 2 days before your appointment (you will not receive a phone call if you confirmed via email).
Yes I Understand
No I Do Not Understand
I have read and I understand the above Financial Policy and I agree to its terms.
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