ࡱ> 8:7_ ~$bjbjzXzX 4,2@\2@\ ff$.***** $3]3**yyy"** y yyy*Pd1'Ry0y<y<y<yy33y<f> :  FINANCIAL POLICY It is our belief that all patients are concerned not only about the treatment that is required, but also how they may handle their account. In order to eliminate any misunderstandings, we feel definite financial arrangements should be agreed upon prior to treatment. Therefore, our purpose is to acquaint you with our financial policies and to give you an estimate for all necessary work required at this time and in the future. Payment is expected at the time of service unless one of the following options has been indicated. The following financial arrangements are available. Please indicate your choice. Option A PAYMENT IN FULL AT TIME OF SERVICE CASH SAVINGS PLAN: We offer a 5% cash savings with payment the day of services for any service over $300. CREDIT CARDS: For your convenience we accept MasterCard, Visa and Discover. Due to the bank handling charge we offer a 3% savings with payment the day of services for any service over $300. CROWN, BRIDGE AND DENTURE SERVICES: All services will be charged out on the seat appointment. Please keep this in mind if you wish to take advantage of the 5% savings. Because of lab fees, we request 1/2 down on the first visit and the remainder at completion. Option B COVERAGE BY DENTAL INSURANCE Balance in full within two weeks of receipt of insurance payment. If the insurance company fails to make payment within 60 days, you are responsible for the full amount owed to Dr.Travis Egesdal. It is important for you to be informed that our professional services are rendered and charged to YOU, not the insurance company. Therefore, you are directly responsible to us for the cost of your treatment. Dental insurance pays only a portion of your investment. Reasonable and customary fees Yearly maximums Pre-estimate terms varies by plan and insurance carrier. To ensure you receive maximum benefits, we recommend that you read your insurance booklet and become familiar with your specific plan requirements. Low reimbursement may be the result of coverage purchased for the insurance plan. Your employer, the purchaser of the insurance plan, selects the range of benefits. If you feel the dental benefits are inadequate, discuss this matter with your employer so that alternatives can be investigated. Please bring your insurance card to each appointment.  H L t   P R T V d 8 : < D ^ |  ߐߌumieaea]ߌh h{hVh#h(*h&V5hKhd5CJ aJ hKhdCJ aJ hBh9* hd5hrrhdCJ aJ h&Vhd5 h&V5h&Vh&V5 h#h&Vh#h&V5hIh#CJaJhlh9=Lhbh&VhIh&V5CJaJhKh&V5>* h#5>*$L R T 8 48TV0]0gd(* 0]0^gdI0]0gdI 0]0^gd&V0]0gddgd&V`gd9=Lgd9=L$a$gd&V 348Dn- 7ȼ駗ȓȓȋzxU h#h(*hbhb56hbh'oh#h.^hIh(*5CJaJ h(*5h(*h(*5h#h(*5hIh#5CJaJh(*h) h.^>*hIh&Vh&V5hdhKhKhdCJ aJ h&VhBh . Crown, Bridge, & Denture services: Patient s predetermined amount due half at prep, half at seat. Balance in full within two weeks of receipt of insurance payment. Option C PAYMENT PLANS/FINANCING Patients wishing to finance treatment fees may be eligible for payment plans/financing through Care Credit. Interest free options may be available. Please ask receptionist or Practice Coordinator for details. In order to comply with the Truth-In-Lending Law, if you wish to make monthly payments on your account, a written agreement must be signed by the responsible party. PLEASE NOTE A monthly finance charge of 1.5% is imposed on all accounts over 60 days (18% annually), with a $3 minimum finance charge. If 90 days have passed since your last payment, your account may be turned over to a collection agency. There will be a $30 processing fee for all returned checks, invalid credit card payments and accounts turned over to collections. ______________________________________ ______________________ Signature of responsible party Date RTVbz|~. !!F!J!L!Z!^!`!r!!!!!!!F"""# $|$˼˼˸˼˴˰ˢϖϖϖϖχς}ςx h(*5 h 5 hb5 h 5 htU5 hB5 h#5 h(*5>*h(*h(*5>*h3h#hBhbhVhKhrrCJ aJ h(*h(*h(*5hIh#5CJaJ h#h(*h.^ h.^56hIh.^CJ aJ -br ##$~$ 0]0^gdV0]0gd(* |$~$ h(*h(*21h:pB/ =!"#Z$% s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List HH # Balloon TextCJOJQJ^JaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. 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