Please note that this agreement states your financial responsibility as a patient of Dr. Scott Wardwell, and addresses the possibility of incurring out of pocket expenses.
As a courtesy, Dr. Scott Wardwell will file an insurance claim for you; however, in the event that your insurance company denies payment for any reason or has not paid your claim within 60 days, you will be responsible for any balance due. We only bill your dental insurance company and are not involved in the management or benefit outline of the contract you’re enrolled in. It is also your responsibility to provide us your current address, billing information and insurance information by carrying an updated insurance card and by following up on any issues with the insurance carrier. We are a dental care provider; our relationship is with the patient and not with the insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility for the date of service rendered.
Estimates & Co-Pays:
Estimated Co-Pays presented to patients either by verbal statements or in written format are due in full at time of service; we accept cash, check, and credit card. Quoted estimate prices are valid for 60 days. Your treatment plan is based on expected insurance reimbursements but is not a guarantee of benefits to be paid by your insurance. It is an estimate. We strive to be accurate in our co-pay calculations, but all insurance companies have a disclaimer when obtaining your benefit outlines that states, “Information provided is never a guarantee of payment.” That being said we do the math off of your benefit outline hoping they will honor their commitment to you and pay diligently on your behalf. If your insurance does not pay within 60 days, or remits less than expected reimbursement the remaining portions then become patient balance as well. I the undersigned understand that billing my insurance is a courtesy extended to me thru Dr. Wardwell's office and he does not bear responsibility for my insurance policy. I am agreeable to these billing terms. I hereby give consent and acknowledgement of the office policies.
*I understand that I am ultimately responsible for either a co-pay portion along with state excise tax, & or full service charges incurred thru denied claims.
*If you have no insurance plan, you will be required to pay 100% of the visit charges at the time of your visit.
Accounts in Collections:
If your account has a delinquent balance, it will be transferred to a collection agency after 30 days. A $50 fee will be added to your account upon transfer. Other charges may include, but is not limited to attorney’s fees and other costs that Dr. Scott Wardwell considers necessary. To avoid collections please understand our office policy is payment in full of all co-pays at time of service. Once being placed in collections we will not be able to schedule any future dental appointments until your account balance is paid in full.
All returned checks will be subject to a $39 NSF fee. You will be required to pay your original balance in addition to the $39 NSF fee before being seen for another appointment. As a result you will be placed on a cash/credit card only payment method for future appointments.
No Show, Cancellation Fees:
As a courtesy to our staff and other patients we request you cancel your appointments with at least a 48 hour notice. If two or more family members are scheduled on the same day a 4 day notice is required. There is a $50 No Show fee, and Short Notice Cancellation fee applied to weekday appointments. All Saturday appointments are subject to a $75 No Show, or Short Notice Cancellation fee. Repeated cancellations or missed appointments will result in loss of future appointment privileges. *Please note that any patients arriving 20 minutes or later after their scheduled appointment time may be rescheduled and/or charged a broken appointment fee as well.
Print Patient Name: _________________________________________________________
Patient/Guardian Signature & Date: _______________________________________________________________
After hour charges:
There are occasions where dental emergencies happen after hours or on weekends that the office is not open. If you contact the doctor after hours and he sees you at the office then an “After Hours” Emergency visit charge of $250 will be charged to your account. Also there are occasions where phone consultation fees are applied to patient ledgers. Phone consults are billed at $20 for every 15 minutes. Both of these fees are not billable to your dental insurance, and are a direct out of pocket expense by you the patient.