Bucks County Smiles Financial Agreement Letter

Financial Agreement Letter

Bucks County Smiles

Dear Patient:

Please carefully review the following financial policy guidelines.

Bucks County Smiles is a non-billing office. We accept cash, personal check, Visa, Mastercard, Discover and American Express; or for your convenience you may visit our website at www.buckscountysmiles.com/payment to pay remotely.

We ask you to pay for your treatment at the time of your dental visit. If your charges are in excess of $400, and you pay in full by check or cash, we will extend a 5% bookkeeping courtesy to you. There will be only one courtesy (discount) applied on an account for each date of service.

If you have a dental benefit plan, we are happy to submit an electronic claim on your behalf. Any dental benefit plan is a contract between you and your dental plan carrier. We cannot guarantee what services will be covered by your plan or what payment amount will be made by your dental benefit plan in contribution to costs of services. Any questions regarding your benefit plan or reimbursement policy should be directed to the benefit carrier or your health benefits coordinator.

Dental benefit carriers will either send payments to you, OR directly to our office.

  1.  If your carrier sends payments to you, full payment for treatment rendered is your
    responsibility on or before the date of service.
  2.  If your dental plan carrier sends claim payments directly to our office, you may leave a credit card number stored in our secured database. When payment is received from the carrier, the credit card will be charged for any unpaid balance. Your benefit carrier will send you a copy of the explanation of benefits paid or rejected, for your records. This is a valuable document, as it outlines treatment submitted, payment made on your behalf, and remaining balance (i.e, the amount that will be charged to your credit card).Please let us know whether you wish to receive a receipt for the credit charges. If your dental treatment fees exceed the benefit plan maximum or amount of benefit available, you will be asked to pay the overage amount on or before the date of service.

You may elect to use Care Credit to cover the cost of your treatment, pending approval. No additional discounts or courtesies will be applicable using this plan. Please ask for information from our treatment coordinators in order to apply for this payment plan either in our office, or in the comfort of your home via computer or telephone.

If, after 60 days, any unpaid balance that does not have a qualifying payment agreement in place will be charged a finance fee of 1 1⁄2% per month. The patient will be responsible for all collection procedure fees. Any appointment that is broken or cancelled with less than 24 hours’ notice will be assessed a fee of $50 per half hour of appointment time. We will charge a fee of $25 for returned checks.

Thank you for your cooperation regarding our Financial Policy. We promise to provide oral healthcare of the highest standards to you, our valued patient.