Minor Patients. In the case of divorced or separated parents, it is YOUR responsibility to have financial arrangements made according to the divorce decree before treatment begins.
Minor Patients. The adult accompanying a minor and the parents (or guardians) of the minor are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless services have been pre-authorized by the parents (or guardians) and payment has been made before or at the time of service in accordance with item number 3 above.
Minor Patients. The adult accompanying a minor and/or the parents (or guardians) are responsible for full payment at the time of service.
Minor Patients. Regardless of marital status, we will look to the adult accompanying the patient for payment due at the time of service rendered to the minor patient. If a parent, other than the one accompanying the minor patient to the office, is legally responsible for medical charges, the accompanying parent will be responsible for payment as we are not a party involved in the divorce decree. We will provide a statement showing payment made that can be provided to the financially responsible adult for reimbursement. OTHER SERVICES REFERALS: Our office requires at least 48 hour notice to request a referral, unless the medical visit is a true emergency. It is the specialist responsibility to ensure there is a referral in place prior to your appointment, not our responsibility. Waiting until the day of the appointment and requesting that we do a referral could cause your appointment to be rescheduled and we regret we have to do this. Make sure your specialist has the referral prior to your arrival. It is the responsibility of the specialist to ensure they have a referral. MISSED APPOINTMENTS/ LATE CANCELATIONS/LATE ARRIVALS: Missed appointments represent a cost to us and a missed opportunity to for another patient to be seen during that time we saved for you. Chronic missed appointments can lead to “working you into our schedule” or being dismissed from the practice. Late arrivals that are more than 15 minutes late will possibly rescheduled based upon the description of the physician or practitioner. Habitual tardiness can lead to us determining the best time for our office to work you into the schedule. PRESCRIPTION REFILLS: Please allow 24-48 hours for refills. Refills will be addressed from Monday-Friday 8:30-4:00pm.If the refill comes in after 4:00pm, it will be addressed the next business day. Narcotic/controlled substances will not be filled on the weekend. Constant calling to see if your medication has been refilled will not speed up the process. Most prescriptions are done electronically and can be monitored by our office and software company to ensure compliance. We do not fill medication to last one year. We try to accommodate patient with cost, but we will not put refills on narcotics/controlled substances.
Minor Patients. The parent/guardian of a minor is responsible for payment of the minor’s account balance. Responsibility for payment of treatment of minor children, whose parents are divorced, rests with both parents. Any court-ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Napa Centre.
Minor Patients. The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit. RETURNED CHECKS A $25.00 charge applies when a check is returned by the bank.
Minor Patients. The parent or guardian accompanying the minor is responsible for full payment. If someone else is bringing the child we need to have your permission to discuss treatment and or approve of treatment needing to be done in the office that day by that adult. At that time we can also let you know the copay so the adult bringing them can be prepared. RETURNED CHECKS: A $25.00 charge applies when a check is returned by the bank. FINANCE CHARGES AND REBILL FEES A finance charge or rebill fee will be applied to all balances not paid within 60 days of the monthly billing date. A late charge of 1.5% on the balance then unpaid or a 3.00 fee for rebill (the higher of the two) will be assessed each month until paid. It is your responsibility to ensure your insurance company pays promptly so you can avoid finances charges. ANY BILLING DECREPANCIES MUST BE SETTLED WITHIN 30 DAYS OF THE FIRST BILLING DATE.
Minor Patients. The parent or guardian accompanying the minor is responsible for full payment. In the case of divorced or separated parents, the parent accompanying the child is responsible for payment, without any exception. This office will not attempt to collect payment from a parent that is not present in the office at that visit.
Minor Patients. The adult accompanying the minor is responsible for the payment on the account. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-paid. Initial
Minor Patients. In a case of divorced or separated parents, it is your responsibility to have financial arrangements made before the treatment begins. Payments for services for the treatment of minors is the responsibility of adult accompanying the minor and will be due at the time of service. Missed appointments: To reschedule or cancel an appointment, you must notify our office at least 24 hours in advance to avoid a missed appointment fee of $75.00. We reserve the right to terminate professional treatment for any patient when scheduled appointments are not kept. I have read and understand this document outlining the financial policies for Saco River Dentistry and agree to these terms. For the mutual convenience of you and the practice, it is understood that this executed copy of the Financial Agreement shall cover your dependent children who are patients of the practice. Signature of Patient or Parent/Guardian SSN
