I Agree to pay for all services rendered at Cornerstone Dental. I understand that payment is due in full, on the day that services are performed. I understand that payment is in the form of cash, check, Visa, MasterCard, Discover, American Express or Care Credit. Any revolving balance will be charged a finance charge of 2% per month, after 60 days, with no exceptions. We suggest that any payment arrangements be made in full within 60 days to avoid any finance charges.
We offer a complimentary 10% senior discount for patients over age 65. More than 1 discount does not apply. There is a $50.00 gift of health for referring family and friends to our office. If you refer someone to our office they must tell us who referred them and show up for the appointment with the referral card. We will give $50.00 to you as a patient.
I am also aware that dental insurance is a contract between your employer, the insurance company and you. Cornerstone Dental is a participating provider with Delta Dental Premier, Delta Dental PPO, Aetna PPO, and Metlife only. We do not accept assignments as full payment. We work with all other insurances and will submit for any services rendered to your insurance company as a service to you. Any phone calls necessary to recover payment for services paid for the patient, after insurance forms are sent to the insurance company is the responsibility of the patient, not of the office. We do not make any follow up phone calls. We will, however resubmit unpaid insurance claims if the patient has not received payment within 60 days.
Our administrative staff may be able to give you an estimate of what your insurance company may cover. We are not responsible for any incorrect quotes. We recommend a pre-authorization with your insurance company to insure an accurate figure of what your insurance company may pay. Please be aware that a pre-authorization does not guarantee payment.
Our office has a broken appointment policy. If you do not cancel your appointment at our office with 24 hours notice or fail to show up there may be a $75.00 broken appointment charge applied to your account. We do know circumstances arise and emergencies happen and this will be taken into consideration.
If further financial assistance is needed, an application for a line of credit is available. We are pleased to offer our patients CareCredit, Chase Health Financial and CitiHealth Card. Please ask us for an application.
I am in agreement with the above financial policies of Cornerstone Dental.