Reviewing the Financial Policy with New Patients/Clients
We are pleased to welcome you as a new patient. Our primary mission at Dr. Holleron’s office is to deliver the best and most comprehensive dental care available. An important part of this mission is making the cost of optimal care as easy and manageable as possible.
To assist you with your dental care investment, we provide the following payment options:
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Cash – includes money orders and personal checks.
- Visa/MasterCard/American Express/Discover – we accept credit cards as payment for treatment.
- CareCredit – patient payment plans that allow you to pay over time with convenient low minimum monthly payments. With CareCredit, you enjoy these benefits. *
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Flexible financing options
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No annual fees or prepayment penalties
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Quick and easy application
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Receive a credit decision almost immediately
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Start your recommended treatment immediately*
We are happy to offer these choices so that you can select a payment option that best suits your needs. We have enclosed more information on CareCredit so that you can make an informed decision about which payment option you prefer.
Our business is based on a time sensitive schedule. Our hygiene appointments for new patients are 1 hour and 10 minutes in length, so if you fail to show for your reserved appointment or cancel without a 48 hour notice there will be a $40 fee. This charge will not be covered by your insurance policy and would therefore be a patient liability.
We look forward to seeing you at your scheduled appointment. Again, we are pleased to welcome you as a member of our client family.
Sincerely,
Barry W. Holleron, D.D.S
*Subject to credit approval
Financial Policy
Please print this form and complete before your appointment. You can bring it with you or fax to 210-829-4604 (Form will be provided by client)
Thank you for choosing Tooth Acres, Inc. as your dental provider. We are committed to providing you and your family with the best in dental care.
We ask that all responsible parties read and sign our financial policy as well as complete the patient information forms prior to seeing the dentist.
Payment for all services will be due at the time services are rendered. In order to serve you better, we accept MasterCard, Visa, Discover, American Express, cash, checks or Care Credit if you choose this option. As a courtesy to you, it is the policy of Tooth Acres, Inc. to bill your insurance carrier, although you are ultimately responsible for the entire bill. As the responsible party, please understand:
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Your insurance policy is a contract between you, your employer, and the insurance company. We are not a party of contact. Our relationship is with you, not your insurance company. We will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and “usual customary” charges. As your dental provider, we will only supply factual information to facilitate claim processing.
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Fees for services, which include unpaid balances, deductibles, and co-payments, are due at the time of service. Returned checks and unpaid balances may be subject to collection placement and collection fees.
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All charges are your responsibility, whether your insurance company pays or does not pay. If your insurance carrier does not remit payment within 60 days, the balance will be due in full from you. If any payment is made directly to you for services billed by Tooth Acres, Inc., you recognize an obligation to promptly remit payment to Tooth Acres, Inc.
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I understand and agree that if I fail to make any payments for which I am responsible in a timely manner, after such default and upon referral to a collection agency or attorney by Tooth Acres, Inc., I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees, and attorney fees.
At Tooth Acres Inc., we understand that financial problems affect timely payment, so we encourage you to communicate any such problems to us, so that we may assist you in keeping your account in good standing. If you have any questions, please call 210-829-7651.