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Willowdaile Family Dentistry’s Financial Policies

The following Financial Policy is required prior to any dental treatment. Please understand we do not want to see financial constraints and/or broken appointments interfere with dental care and the doctor/patient relationship. To facilitate your payments, the following options are listed. Please read them carefully and sign the designated line in agreement.

Patient Name: ________________________________________________________________

Name of Person Responsible for Account: ____________________________________

Relationship to Patient: _______________________________________________________

Drivers License #: ____________________ State: ________ Exp. Date: ______________

Date of Birth: _________________________ SS# ___________________________________

Employer Name & Work Phone #: _____________________________________________

Payment Options:

IF YOU DO NOT HAVE INSURANCE, payment is due in full at the time treatment is provided. For your convenience, we accept Cash, Personal checks, MasterCard, Visa, and Care Credit financing, pending credit approval.

IF YOU HAVE INSURANCE, we will submit your insurance claim to your insurance carrier as a courtesy to you. The amount of coverage paid by your insurance company may be based on your insurance company's Usual and Customary Rates and/or Fee Schedule. Please note: we are not contracted with any insurance company. You are responsible at the time of your appointment for any deductible and co-pay not covered by your insurance company, as well as any remaining balance that they fail to pay. (Delta Dental patients are required to pay in full, because patients are automatically reimbursed). If your insurance company does not remit payment within 60 days (and we will make every effort to help this happen), the balance will be due from you and may be subject to service charges. Outstanding balances are due prior to scheduling your next visit.

Broken Appointment Policy:

Dr. Bolton and staff are striving to provide the best quality care to our patients in an efficient and timely manner. Appointments are reserved exclusively for each patient and are also customized according to individual needs. Missed or broken appointments effect many schedules and could be used for another patient in need. The doctor and staff have prepared for the appointment. Materials and treatment setups are wasted, thus increasing the office operating costs. We ask that you keep your scheduled appointments to help us keep our fees low and our efficiency high. We thank you for your cooperation and gesture of good will.

If you are unable to keep your reserved appointment, please give us at least 24 hours notice. If you have a Monday appointment and need to cancel or reschedule, you need to contact our office no later than Thursday, the week before. Arriving over 15 minutes late is considered a broken appointment. We charge $25 per hour scheduled for all broken appointments, no shows, and rescheduled appointments if less than 24 hour notice is not given.

If a second broken appointment occurs, we will NOT reschedule your appointment at that time to be fair to our other patients that would have used your reserved time slot for our services. Instead, we will place you on a short-notice list and we will call you when we have an appointment time available. In addition, you will also be required to PRE-PAY for your next appointment in FULL, as well as any broken appointment fees.

Additional Costs:

I am responsible for attorney fees, collection agency fees, billing fees, interest charges, small claims court costs and any other expenses incurred in collecting my account if it is not paid for in full within 90 days of the date of service.

Checks:

We encourage the use of check cards and you should receive one free with your bank account. Due to the abnormally high rate of receipt of bad or stolen checks, we will not longer be accepting personal checks. We apologize for any inconvenience.

I agree to the above financial policies set forth by Willowdaile Family Dentistry:

Signature of Responsible Party: _____________________________ Date: _______________