FINANCIAL POLICY and INSURANCE  AGREEMENT

     We are committed to providing you with the best possible care.  If you have dental insurance, we are anxious to help you receive your maximum allowable benefits.  In order to achieve this goal, we need your assistance and your understanding of our payment policy.

       Payment for services is due at the time services are rendered unless payment arrangements have been approved in advance by the doctor.   If you have dental insurance, we are happy to bill the insurance for you, but please be aware that billing the insurance is not a guarantee of payment. 

    1.  Your insurance is a contract between you, your employer, and the insurance company.  We are not a party to that contract.

     2.  Most insurance companies have a deductable that must be met before the company will pay their portion.  If you have not met your deductable for the year, you are responsible for any charges until the deductable is met.  Even after the deductable is met, most companies still only pay a percentage (such as 50% or 80%) and you will be responsible for the remainder.

     3.  Not all services are a covered benefit in all contracts.  Some insurance companies arbitrarily select certain services they will not cover.  Dental offices are not able to change those services in favor of the patient.

In an effort to provide you with quality dental care; we have expanded our payment policy. We will use our expertise to help you obtain the maximum benefits from your insurance policy.  We expect full payments when services are rendered unless prior arrangements are made.

 PLEASE SELECT DESIRED PAYMENT METHODS 

__Payment by Cash or Check. (Uninsured patients may receive a 5% payment in full discount.)

__Payment by Credit Card (Visa/MasterCard) at time of service.

__Automatic billing to your Visa/MasterCard if a payment plan has been approved.

INSURANCE:  We will file your insurance claims.  You are expected to pay in full if we cannot verify your insurance coverage at the time of service.  We will gladly issue a refund or credit once dental insurance is confirmed, billed and we have received payment.    If insurance is billed at time of service, any balance or deductable not covered by insurance will accrue a monthly finance charge of 1% after 30 days.  (Please note: payment in full discounts and senior discounts may not be applied to unpaid insurance balances.)

  We will gladly discuss your proposed treatment and answer any questions relating to your insurance, you must realize, however, We must emphasize that our relationship is with you, the patient, and not with your insurance company.  While we will bill your insurance company for treatment rendered, the Doctor will not base his treatment on what the insurance company will pay but on the immediate needs of your oral health.  Ultimately all charges are the patient's (or patient's guarantor) responsibility. 

CHARGES: You will be responsible for all insurance deductibles, patient co-payments, the remaining balance of charges not paid by insurance within 30 days, broken appointment fees and any outstanding balance on your account which includes any dependants for all services rendered by Dr. Greg Ganzkow DDS.

There is a monthly interest of 1% (12% annually) for all unpaid balance after 30 days from the date of service. 

BROKEN APPOINTMENTS:  We reserve the right to charge $150.00 per half hour for all failed appointments without 24hrs prior notice.  For appointments two hours or longer, we need to be notified 48hours prior.   We understand that emergencies do occur without notice, so to avoid a billing for the Doctor’s lost time, please call our office immediately and discuss the situation with our office manager.  Please specify the best phone number on your patient registration chart for appointment reminder calls.  Monday appointments will be called the previous Thursday.  Tues/Wed/Thurs appointments will receive a call the previous afternoon. 

PLEASE SIGN TO ACKNOWLEDGE OUR OFFICE FINANCIAL POLICY

 I assign my insurance benefits to the provider listed above.  I understand that this form is a valid financial agreement.  I certify that I have read and understand the above information.

Signature of Patient/Guarantor_____________________________________Date:__________________

 rint Name:__________________________________________