Financial & Office Policy

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ANTHONY R. LINE, DDS. PA

This agreement is considered active/valid unless updated Please Initial Each Item Below

PAYMENTS:*

I understand that I should expect some sort of copay / co insurance at the time of service. I will come prepared to pay that upon leaving the office. I understand the office will file all insurances as able and in the event of an overpayment I will promptly issued a refund. Typically an amount of 20% is expected following treatment and prior to insurance filing with the exception being exams and cleanings.

INSURANCE:*

I Understand that it is my responsibility to confirm with my insurance company that this dental office is under contract with my insurance carrier or that I am willing to pay out of network benefit fees. Any questions about insurance coverage will first be directed to my insurance carrier. I agree to be responsible for all copays and non-covered services

OVERDUE BALANCES:*

Although exceptions may apply, I understand that all unpaid balances that I have not made arrangements to pay may be forwarded on to a collection agency after 90 days. At that time dismissal from the practice will occur and a 25% collection charge may be added to the overall total to cover the collection fees. This practice will do everything it can to work with me to avoid that result.

CANCELLED / MISSED APPOINTMENTS:*

I understand that I am expected to notify the office within 24 hours if I am unable to make a previously scheduled appointment. I realize that unexpected circumstances may arrive but I will do my best to arrive on time or give adequate notice. I understand that if my cancellations or misses become habitual I may be charged a missed appointment fee

ANESTHETIC & DENTAL MATERIALS USE:*

I understand that if I require any dental anesthetic use or other materials (impression materials, filling materials, bonds, fluoride, etc) that I am consenting to their use and all potential side effects (prolonged numbness, injection site pain, nerve damage, muscle pain or irritation, contact dermatitis, etc). If I have any allergy or sensitivity to those materials I will include it in my medical history and make the providers aware prior to any appointments.

HIPPA:*

I am aware of the Health Information Privacy Act and all that is included. I have the opportunity to view the policy if I desire. I understand that my information may be shared with my dental insurance company, any specialist office I may be referred to, and any family member I allow.

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Financial & Office Policy

ANTHONY R. LINE, DDS. PA