Financial Policy And Insurance Agreement

We are committed to providing you with the best possible care. In order to achieve these goals, we need your assistance and understanding of our payment policy. Payment for services is due at the time services are rendered. We accept cash, checks, debit, Visa, MasterCard, Discover, American Express and Care Credit.

1. Returned checks are subject to all costs for bank fees, in addition to a $75.00 penalty fee.
2. I understand that I may be charged a 1.5% per month or 18% per year finance charge if my balance goes beyond 90 days.
3. I understand I am subject to a $50.00 fee for broken appointments, as well as appointments cancelled without a 48-business hour advance notice, in addition to a $35.00 per hour increment of the broken appointment that was reserved for me, based on the time reserved for my dental appointment with the doctor and/or hygienist.

If you have dental benefits, we will assist you in obtaining your maximum allowable per year. You must realize, however, that:

1. I understand that my insurance is an agreement between me and my insurance company. I also understand that I am responsible for my balance regardless of my insurance. If my insurance company fails to pay a claim within 45 days of filing, I am then responsible for complete payment of the balance due.
2. I understand that my insurance benefit plan is a contract between me, my employer, and the insurance company. Main Street Dental is not a party to the contract.
3. I assign dental benefit payments to be paid directly to Main Street Dental, LLC / Dr. Crystal Camden from my insurance company.
4. Our fees are generally considered to fall within the acceptable range (UCR) by most companies and therefore are covered up to the maximum allowance determined by each carrier.
5. Some insurance companies arbitrarily select not to cover certain services in their contracts, which I may be responsible for.

I hereby ask and authorize payment from my insurance company directly to Main Street Dental / Crystal Camden, DMD. It is considered a method of reimbursement for fees paid to the doctor and is not a substitute for full payment. I also understand that I am responsible for all costs of dental treatment, including, but not limited to, any fees my insurance company does not cover. I also authorize the release of any information relating to my claim. In the event of a problem, I hereby ask and authorize Main Street Dental to speak with the Insurance Commissioner on my behalf.

I understand that billing correspondence, including statements of outstanding balances, will be delivered electronically via email, whenever possible, and it is my responsibility to make payment for any outstanding balance.

I also authorize that insurance overpayment will remain in my account as a credit balance toward future services and are not transferable. Reimbursement requests for overpayment may be made in writing. Refunds will be made in the same manner as the initial transaction and may take up to 4 weeks to process.

I hereby authorize the dental office to administer such medications and perform such diagnostic and therapeutic procedures as may be necessary for proper dental care.

Should it be necessary to collect my account through an attorney or collection agency, I hereby agree to pay all costs of collection, including attorney’s fees, collection costs, and court costs.

I have read and fully understand the above information and agree to its conditions.

Signature

Main Street Dental 5205 Office Park Blvd. Bradenton, FL 34203 (941) 725-1128

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.