Financial Policy Form

Our primary goal is not to allow the cost of treatment to prevent you from being able to receive the care that they need.

Insurance

Ultimately, however, You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates. We are happy to submit the claims necessary to see that you receive the full benefits of your coverage; however, we cannot guarantee any estimated coverage. Because the insurance policy is an agreement between you and the insurance company, we ask that all patients be directly responsible for all charges. Please know that we will do everything possible to see that you receive the full benefits of your policy by electronically filing your claim the day of your appointment. If there are any complications, we will assist you with any information you may need. Please remember that your insurance policy is a contract between you and your insurance provider. We will, as a courtesy, bill your insurance to help you receive the maximum benefit under your policy. It is your responsibility to provide all necessary insurance identifications, understand your eligibility and notify us immediately of any changes. It's also your responsibility to ensure that our office is a participant with your insurance plan. Although we are providers of multiple PPO network plans, we do accept most insurances.

Check if you have read the above statement

All Co-Pays and Deductibles will be due at the time of service
Pre-estimates can be submitted on your behalf, please understand they are simple an ESTIMATION of patient cost

Do you have dental insurance that we may file on your behalf and accept assignment of payment?

Yes

Payment Options

We make payments convenient as possible by accepting Cash, Check, Master Card, Visa and American Express. Payments can be made via phone during regular office hours.

All services without insurance submission are due in full the day of treatment
Internal Financing is available up to three months – a Credit Card must be placed on file
A $35 fee will be applied to all returned checks
Balances over 90 days will be turned over to an external collection company
Account must be paid in full prior to each 6-month cleaning and exam appointment

Agreement

I understand and fully agree that I am responsible for my account balance. I agree that if turned over to a collection source, I will be responsible for fees above and beyond my account which may include attorney and court fees. I understand that if my account becomes overdue or uncollected, it can result in cancelled appointments and dismissal from the practice. Lastly, if insurance is involved, I take full responsibility for any following up on all claims su

Patient Signature

Guardian Signature

Date

Patient Name

Patient DOB

I hearby acknowledge that I have been offered a copy of Burns Family Dentistry's Notice of Privacy Practice (Patient/Parent/Guardian)

Permission to Share Medical Information

May we leave medical and appointment information via voicemail?

Yes

Preferred Phone #

My Medical Information may be obtained and/or disclosed to the following people:

Name/Relationship

Check if you agree to the above referrals (Patient/Parent/Guardian)

Permission to Bill Your Insurance

All professional services are charged to the patient. Burns Family Dentistry will help expedite insurance carrier payments by filing necessary claim forms. However, the patient is responsible for all fees, regardless of insurance coverage.

I understand my signature authorizes Burns Family Dentistry to release necessary information to my insurance carrier.

Signature of Patient/Guardian

Date

At Burns Family Dentistry taking care of patients in a safe and timely manner is our daily purpose. Taking a customized approach means that we have to have a certain level of predictability each day. We try diligently to schedule each appointment at a time that works best for your schedule. We understand that emergencies arise, creating a change in a scheduled appointment. However, for each patient to receive dedicated attention and care, we ask that patients follow the Appointment and Cancellation Policy for BFD.

You will receive call, email or text confirming your appointment 7 days prior. Please confirm it so there is no interruption in the time. You will also receive a Reminder Call 1 day prior to the appointment.
We will always strive to schedule any next appointments when you are in the office. Please have your calendar with you so we can look for the time that best serves you.

Late Appointments

Because we work hard to customize each and every visit, it does requires careful planning and the allocation of our team to specific patients. Late appointments negatively impact the schedule.

If you are more than 15 minutes late, we reserve the right to reschedule the time
Multiple late appointments will result in restricted scheduling and/or dismissal from our practice.

Missed Appointments

We require 24 hours advanced notice of a cancellation
If you have more than two missed appointments or short-notice cancellations, it could result in dismissal from our office and /or a $25.00 Rescheduling Fee

I have read and understand the Appointment and Cancellation Policy. I as well understand that not following this Policy may result in additional fees, and the disruption of the ability to schedule.

Printed Guardian Name

Guardian Signature

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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