Bucks County Smiles Financial Policy

Dear Patient:

Thank you for choosing Bucks County Smiles to be your dental provider. Please carefully review the following information regarding our consent for treatment and financial policy guidelines.

Consent for treatment and financial arrangements

I the undersigned, hereby authorize Bucks County Smiles to take radiographs, study models, photographs, records or any other diagnostic aids they deem appropriate to make a thorough diagnosis of my dental needs. I also authorize Bucks County Smiles to perform all forms of treatment, medication and therapy that may be indicated. I authorize and consent Bucks County Smiles to employ any such assistance as they deem appropriate under the law. I further authorize the release of diagnosis, radiographs, patient records, treatments or examinations rendered: to my insurance company, consulting professionals and others I approve.

Bucks County Smiles is a non-billing office. We accept cash, personal check, Visa, Mastercard, Discover and American Express at the time of your dental visit

All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that, as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. 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.

• If your carrier sends payments to you, full payment for treatment rendered is your responsibility on or before the date of service.
• You will submit payment at the time of service for the patient portion of your balance that is not covered by your insurance. As a reminder, your insurance benefits are estimated and based upon the determination of your insurance carrier. You may leave a credit card number to be stored in our secured database to pay for any balance not covered by your insurance carrier. 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 the 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.

Patient Financing Options

Bucks County Smiles provides various convenient options for our patients to pay for their dental care.

• You may elect to participate in the Patient Pre-Payment Plan offered by Bucks County Smiles. This plan offers the patient the ability to pre-pay for their treatment. Ask one of our Treatment Coordinators about this plan to determine the various options that are available specifically to your treatment plan.
• You may elect to use CareCredit or LendingPoint to cover the cost of your treatment, pending approval (minimum applicable procedure fee of $400). 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.

Past Due Balances

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney’s and collection fees. After 60 days, any unpaid balance that does not have a qualifying payment agreement in place will be charged a finance fee of 1.5% per month. The patient will be responsible for all collection procedure fees. We will charge a fee of $25 for any returned checks.

Broken Appointments

Reservations require a great deal of setup and preparation tailored to you and your treatment. Last-minute cancellations and missed reservations will be subject to a charged fee of $50.00. To avoid this charge, please contact our office within 48 hours (about 2 days) of your reservation to make changes to your appointment(s). We do understand that, on occasion, last-minute things do occur. If we both take our commitment to each other seriously, these issues are often avoidable.

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