GENTILE DENTAL CARE
    BILLING PAYMENT POLICY


    Thank you for choosing Gentile Dental Care as your dental provider. We are committed to providing you with the finest care available. Therefore it is very important that we understand and agree upon the financial obligations which will be incurred as a result of the services rendered. Please read the following policy and sign below.


    1. IF YOU HAVE INSURANCE COVERAGE
      1. PROOF OF INSURANCE: It is your responsibility to provide current valid proof of insurance. If you fail to provide us with the correct information or do not have an up-to-date insurance card, we cannot properly file your claim and you will be responsible for all charges incurred. Please contact your insurance company if you are unsure of your coverage
      2. COVERAGE: If your insurance changes, please notify us before your next visit to avoid unexpected charges.
      3. CLAIMS SUBMISSION: As a courtesy, Gentile Dental Care will file a claim with your insurance company for any services provided and assist you in any way we can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim.
      4. CO-PAYMENTS AND DEDUCTIBLES: All non-covered portions, co-payments and deductibles are due upon delivery of products or services and must be paid at the time of service unless an alternative payment method has been agreed upon in writing.
      5. DEPOSITS/DOWN PAYMENTS: Prior to beginning any work, we will estimate the co-payments. Deductibles may incur based on the information we obtain from you and your insurance company.
      6. NON-COVERED SERVICES: Please be aware that some services and/or products may not be covered by your insurer. You must pay these services in full at the time of the visit unless other financial arrangements have been made in advance.
    2. IF YOU DO NOT HAVE INSURANCE COVERAGE
      • If you do not have insurance coverage, payment in full is due on the date of services. We offer financing options which we will gladly discuss with you. We will gladly help you with the application process for any of these healthcare credit plans.
    3. NON-PAYMENT/DELINQUENT ACCOUNT
      • Please be aware if your account is 90 days past due, it may incur a billing charge.
    4. THERE IS A CANCELLATION FEE OF $75 FOR ALL PATIENTS THAT NO SHOW OR CANCEL A SCHEDULED APPOINTMENT WITHIN 24 HOURS OF THE APPOINTMENT TIME.

    It is not our intention to place our patients in a position of hardship or financial burden. However, it is important to resolve outstanding balances in a mutually agreeable fashion so that we can continue to provide our patients with high quality care. It is for this reason that no exceptions will be made to this policy without a written agreement. If you need financial consideration, it is your responsibility to request it prior to the provision of products or services. Thank you for your understanding and cooperation in this matter. We accept cash, and all major credit cards for payment

    Date:

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    GentileDentalCare

    A prosthodontist is a dentist who specializes in the esthetic restoration and replacement of teeth.

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    Our staff is professional and courteous with everyone who walks through our doors. We strive to give exemplary care in our practice by communicating with our patients and agreeing on a treatment plan that best suits them aesthetically, and financially.

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