Briargate Dental Center.
To reduce our administrative costs and keep our fees to you as low as possible, all fees not covered by your insurance are due in full at the time you receive treatment. Please note that we can only estimate what your insurance may cover. If you do not have dental insurance, all fees are due in full at the time you receive treatment. We will gladly submit your claims to your insurance carrier as a courtesy. Account balances are due as soon as insurance issues payment or within 60 days, whichever is sooner. If your insurance company has not paid within 60 days, you will need to contact the insurance company, while paying your balance with us in full.
Insurance information is provided as a courtesy and for your convenience only. We cannot nor do we attempt to guarantee any insurance coverage. We can only provide an estimate of the amount your dental plan may cover, as it is virtually impossible to predict what each insurance plan will pay. It is your responsibility to understand the limitations and provisions of your insurance policy. Your insurance carrier determines the amount that it will pay on your claims. If you have questions concerning your deductable or co-insurance percentages, please contact your insurance company directly.
We are currently in network providers for the following Insurance companies. Cigna-Radius, Delta-Premier, Guardian, MetLife, Principle and United Concordia. Because we can only estimate your insurance coverage, you may have a balance due after we receive payment from your insurance carrier. An 18.50% interest fee will be added to all balances over 30 days.
We accept Cash, Check ($50.00 fee will apply to all returned checks), Visa, MasterCard, Discover and CareCredit (must qualify for a no interest line of credit, inquire at front desk for more information)
Patients without insurance coverage can receive a 5% discount on treatment when it is paid in full, cash or check only, at the time the treatment is scheduled. A $50 fee will be added to all returned checks and the 5% discount will no longer apply.
We respectfully request a minimum of 48 hours notice to cancel or change your appointments. The time scheduled is set aside especially for you and we look forward to meeting your dental needs during this time. There is a $50.00 cancellation or no show fee. A broken appointment is a loss to three people – the patient that missed the valuable time, the patient who could have taken the valuable time; and the doctor who was fully staffed and prepared for the appointment.
In the event your account is not paid within 30 days of treatment, or according to an agreed-upon payment plan, interest will be assessed at 18.5% on the unpaid balance. If your account becomes delinquent, it may be forwarded to an outside collection agency without notice. If this happens, you will be responsible for all costs of collection, including but not limited to interest, rebilling fees, court costs, attorney fees and collection agency costs.
My signature below acknowledges that I have read the above, understand and agree to these provisions. I hereby authorize payment directly to the Dental Office of the group insurance benefits, otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the Dental Office to administer such medications, and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health professionals.
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