TD Patient Forms 6/23/08 1:01 PM Page 4
Insurance and Financial Policy
At Today’s Dental, we believe that you deserve the best care. That’s why we always present you with the best dental solution
possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have den-
tal benefits but some don’t. If you have dental benefits, congratulations! You are very fortunate. Here are some important things
you should know:
Initial
_______ ■ Your dental benefits are based upon a contract made between your employer and an insurance company. If you have
any questions regarding your dental benefits please contact your employer or insurance company directly. Dental
benefit plans will never pay for completion of your dental care. It is only meant to assist you.
_______ ■ We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or
require our office to accept a reduced fee for service). This means that we work with literally thousands of compa-
nies. Although we can maintain computerized histories of payment by a given company, they do change; therefore
it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most
up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your insurance bene-
fit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment. Keep
in mind this is not a guarantee of coverage. This does delay treatment but will give you the exact out of pocket fig-
ures you may require.
_______ ■ We will bill your insurance as a courtesy. If insurance does not pay within 90 days, Today’s Dental reserves the right
to request payment in full for services from you and let you collect the insurance funds that are due to you. This is
rare but it is important that you recognize that the insurance you have is a legal contract between YOU and your
insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for
all charges incurred in our office.
_______ ■ Today’s Dental does require payment in full for your portion at the time of service. We accept MasterCard, Visa,
American Express, Discover, cash, and checks (for existing patients with established payment history). We do not
accept checks for over $500.00 for any patient. If you are in need of an extended finance option, we also work with
CareCredit, who offers 3, 6, 12 or 18 month “same as cash” or longer terms with an interest bearing revolving charge
designed to meet your treatment plan needs on approved credit.
_______ ■ A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appoint-
ments. If you must change your appointment, we require at least 24 hour notice to avoid a $35/hour cancellation
fee (emergencies are an exception).
_______ ■ In the event of an emergency after regular business hours a $55 emergency fee will be charged for established
patients in addition to the necessary treatment fees. Patients who are not established in the practice will be charged
$125 after hours emergency fee.
I agree with the above conditions.
Print Name:_________________________________________________________ Date: _________________________
Patient/Parent Signature: ______________________________________________________________________________
