Financial Arrangements And Office Policy Form

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Financial Arrangement and Office Policy

For All Patients:

Payment is expected as services are rendered unless prior financial arrangements have been made. If treatment requires multiple appointments, payments may be divided over the number of appointments. Cash, personal checks, VISA, MasterCard, and Discover are all accepted. If an extended payment plan is desired, please ask us about our third party billing (finance) program. A 5% senior citizen discount is also offered, but cannot be combined with any other discount. Delinquent accounts over 90 days will be referred to a collection agency. All fees incurred from the collection agency will be charged to the account. If legal action is necessary then all fees are the responsibility of the patient.

For Patients with Dental Insurance:

We will be happy to process your insurance needs as a courtesy to you. Please note not all services may be covered by your insurance carrier, and every insurance plan has its own "quirks", exclusions, limitations, allowances, fees and expectations. We will do our best to estimate your insurance portions; however, it is ultimately your responsibility to be aware of your own personal insurance benefits. Our estimation of dental coverage is only an estimate, as we cannot guarantee what your individual insurance will cover and/or exclude. Insurance companies have not changed their benefit amount to you, their client for over forty years. The insurance companies continue to increase their premiums to you, but refuse to increase their benefit. It has become the patients responsibility to pay all fees on procedures that are not covered by their insurance plan.

Office Policy:

We reserve your appointment time exclusively for you. Keeping these needs in mind we request 48 hours notification if an appointment absolutely must be rescheduled. If less than 48 hours notice has been given, a $50 fee will be assessed. In the event that no notice is given and the patient does not show up for their scheduled appointment, then a $75 fee will be assessed. As is your time, our time is extremely valuable to us and to our patients. Please respect the time that we scheduled for you and we will, in turn respect your time that you have given us. Please notice that this fee is not covered by dental insurance and payment is the patients responsibility. Two no-shows can result in dismissal.

Patient Privacy:

Our practice is committed to securing the privacy of your health information. Accordingly, we have provided you with a copy of our practice's Notice of Privacy Practices & Dental Materials Fact Sheet. You are not required to read this notice. However, we would like your acknowledgement that you received this Notice of Privacy Practices and Dental Materials Fact Sheet. Cell Phones:Please turn off all cell phones prior to entering the treatment area. Again, interruptions of dentist and assistant can affect the quality of treatment.

Signature:

Date:

Patient Name:

Our Promise:

We at Locascio Family Dentistry thank you for choosing our office as your oral health care provider. We are a "patient-centered" dental office and provide comprehensive, modern dental care to our patients. We strive to maintain our standards through patient service, professionalism, compassion, efficiency, and continuing education. Every staff member takes pride in achieving high standards in dental excellence and value forming lasting relationships with our patients. We welcome you and your family to our dedicated team of dental professionals.

Locascio Family Dentistry

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