FINANCIAL POLICY

Thank you for choosing Tooth & Co for your dental care.  We are committed to providing the highest quality care and service.  We will recommend the appropriate and needed services without regard to the limitations imposed by insurance coverage.  Our practice is “patient centered” rather than “insurance driven”. The following is a statement of our Financial Policy which we require you to read, initial and sign.

INSURANCE
As a courtesy we offer you an estimate for recommended treatment. All estimated patient portions are due at the time of service. At any time, if you have questions regarding your dental plan as it relates to your treatment, we will be happy to answer them to the best of our knowledge. However, we encourage you to refer to your benefits manual or call the customer service if you have any questions about covered services on your plan. Please keep in mind your insurance is a contract between you and the insurance company. Your involvement in the process of providing us with proper information, and you being proactive in knowing your plan, will help to maximize your benefits to their full potential. It is your responsibility to verify plan benefits for services with your insurance company.
We are directly contracted with many insurance companies but please note that we are not a provider under any state insurance plans (such as U-care, Minnesota Care, Delta Care, and Medicaid). We will submit insurance claims for providers other than the state plans on your behalf and will do all we can to help in the processing of claims. In the event that your insurance company is slow to pay or disallows the claim payment, the amount owed is your responsibility. In order to file claims, we need the following information (most of the time your insurance card will have this information): Insurance Company Name, Phone Number and Address for claims • Policyholder Name and Date of Birth • Employer for the Policyholder • ID number or Social Security number • Effective date of Policy
Our acceptance of insurance assignments does NOT absolve you of full responsibility for the treatment rendered. The estimate provided is to be considered a guideline until the final insurance payment is received and your account has been reconciled. The estimate is NOT a guarantee of insurance payment. If your plan has a reduced fee schedule or a provider network, it is your responsibility to be sure we are a participating (in network) provider.
ESTIMATED PATIENT PORTION
Please understand that payment of your bill is considered a part of your treatment. The "Estimated Patient Portion" is due at the time treatment is rendered. To help make payment convenient, we have established the following payment options: 1. Cash, check, debit card or major credit card - Visa/MasterCard; 2. Third-party patient financing is available to qualified patients (ask for details at the practice); 3. For our patients without insurance, a 5% savings is offered for pre-payment or full payment with cash or check at the time of treatment. ASK US ABOUT SmileClub, TOOTH & CO'S EXCLUSIVE IN-HOUSE DISCOUNT PLAN AVAILABLE TO PATIENTS WITHOUT INSURANCE.
MINOR PATIENTS
Minors (under the age of 18) must be accompanied by a parent or legal guardian at all their visits. The parent or legal guardian is responsible for the Estimated Patient Portion when treatment is rendered. Should the recommended treatment plan change, approval is required by the parent or legal guardian. The parent or legal guardian is required to notify our office of any changes in the minor's medical history prior to treatment.
DIVORCE DECREES
This office is NOT a party to your divorce decree. The parent or legal guardian who accompanies the minor at the appointment is responsible for payment of the Estimated Patient Portion.
INTEREST AND RETURNED CHECKS
Accounts outstanding more than 60 days from treatment date will be charged 5% interest per month. A $30 service fee will be applied for checks that are returned for any reason.
MISSED APPOINTMENTS
We understand that at times it may be necessary to reschedule an appointment. If that need should arise, we request that you call the practice on a business day at least 24 hours in advance of the scheduled appointment. Unless canceled on a business day at least 24 hours in advance, there may be a Broken Appointment fee charged to your account. The Broken Appointment fee may be applied when an appointment is failed (no call / no show) or when an appointment is canceled without the required advanced notice. This fee is not covered by your insurance and will be your responsibility. Should a pattern of missed appointments be determined, future appointments may be impacted.
Please sign below in acknowledgment of the above financial policies. *
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