Financial Policy For Our Patients

From the office of Dr’s Wilk and  Revoir

 

 

 

To maintain the practice operations and prevent potential misunderstandings, we ask you to accept and adhere to the following financial policies regarding your dental treatment.

 

Insurance:  Our office will gladly work with you to help get the maximum benefit available to you.  Most dental insurance plans do not cover 100% of your cost of treatment.  Because of this, you will be asked to pay your deductible and your co-payment for the charges on the day the service is rendered.  Also for all treatment under $100, excluding preventive treatment, you will be asked to pay in full.  We will estimate as closely as possible your coverage, but we can make no guarantee of any estimated coverage.  Because the insurance policy is an agreement between you and your insurance company, the ultimate responsibility for all charges lies with you.  If after 60 days the insurance company has not paid on the claim, you will be responsible for the total balance.

 

Payment Options (Please choose one discounts cannot be combined):

· Full Pay Cash Discount: We offer a 5% accounting courtesy discount for all treatment that is paid in full (cash or check) at the time of service.

· Senior Citizen Payment Option: As a courtesy to anyone 60 years or older, we will gladly discount your fee by 10% if services are paid in full at the time of service. ©

· Major Service – Two Payment Option:  We offer a two payment option for Crown, Bridge and Denture treatment.  Half will be paid at the first appointment and the balance at the final appointment.  There is no discount available for this option.

· Credit Card Three Payment Option:  We allow established patients with a good payment history to make three equal installments with a preauthorized credit card agreement form.  One third at the first appointment, one third at thirty days and final payment 60 days from initial appointment.  There is no discount available for this option.

· Outside Financing: Option 1 – Care Credit - A dental credit card that can be applied for through our office with an outside financing company.  The application is called in from our office and we usually know within an hour if the applicant is approved

 

 

 

BROKEN APPOINTMENTS:  A specific amount of time is reserved for you and we encourage

all patients to keep their appointments.  If you must change your appointment, we require at least 24 hours notice to avoid a $70.00 cancellation fee (emergencies are the only exceptions).

 

 

 

 

 

Patient Signature  ______________________________________  Date  _________________

 

For Printable .pdf version of our financial policy please click here.