Clarksville Dental Center

Financial Policy

Our offices are committed to meeting or exceeding the standards of infection control
mandated by federal and state governments. In order to keep our fees down and
provide quality dental care with the latest in sterilization techniques and dental
procedures, we have established the following financial policy:
 

1.PAYMENT POLICIES:
Payment for professional services is expected at the
time of service. Payment may be made by cash, check, credit cards or through
other approved lending agencies. Insurance is generally accepted, however any
deductible and estimated co-payments (the part of dental fees not covered by your
dental policy and deductible) are payable at the time of service.
 

2. Patients having dental insurance must provide documented evidence of coverage, i.e.
insurance card, claim form.
 

3. Patients who utilize Dental Health Care Insurance should remember that
professional services are rendered and charged to the patient not to Insurance
Company. Thus the patient is responsible for all charges not paid by their insurance
company.
 

4. Insured patients are expected to take care of their co-payments as services are
rendered. This office cannot accept responsibility for collecting your insurance claim
or for negotiating a settlement on a disputed claim. You are responsible for payment of
your account.
 

5. We allow a reasonable time for your Insurance Company to pay for treatment.
 

6. If you have any questions we shall of course, assist you. Your eventual
reimbursement will be determined by your insurance carrier.
 

7. In the event, the charges incurred are not paid in full when due and collection
action is instituted, whether by a collection agency or attorney, or both, you agree tobe
responsible for and pay, in addition to the charges for services and treatment
received, all costs associated with such collection activity including, but not limited to,
reasonable collection agency fees, attorneys fee, court cost and / or any other
expenses incurred in its collection, according to 1989 statues of the State of Tennessee.
 

8.INTEREST:
Any account remaining unpaid 30 days from date of service, CDC has the
right to charge interest at the rate of 1.5% per month of any unpaid balance (18%
per year) unless prior payment arrangements have been approved.
 

9.LABORATORY DENTAL PROCEDURES:
Crown Bridges, Partials, Dentures, etc: A
nonrefundable laboratory retainer fee of half of the charged fee is due on the day
impressions are taken unless prior payment arrangements have been approved.
 

10.PAYMENT PLANS:
On large treatment cases financial arrangements will be discussed and approved prior to the first treatment visit.
 

11.CHILDREN:
The parent or guardian who brings the child into the office for
dental treatment is financially responsible regardless of dental insurance or legal
responsibility another parent or guardian may have to this child.
 

12.TMJ:  Payment is full must be received when treatment begins regardless of
insurance coverage. We will be glad to assist you in filing for the insurance company to
reimburse you.
 

13.CANCELLATION POLICY:
Patients are expected to notify the office at least 24
hours prior to their scheduled appointment if they cannot keep this appointment. Failure to notify us will result in a charge of $25 for the first missed appointment and $30charge for the second missed appointment. Three non-notified missed appointments may result in dismissal from the practice.
 

14. It is agreed and understood that under the provision of the Fair Credit Reporting
Act, I have been notified that Clarksville Dental Center may perform a credit check to
offer different types of financing. I release all persons who furnish such information to
Clarksville Dental Center from liability and damages.
 

15. Customer, Patient, Borrower, Guarantor, etc. agrees to pay all cost ofcollection
including attorney fees, collection fees, and contingent fees to collection agencies of
not less than 35%, such contingency fee to be added and collected by thecollection
agency immediately upon your default and our referral of your account to saidcollection
agency.

16. I hereby authorize CLARKSVILLE DENTAL CENTER to affix my name to any
and all claims or documents as related to any and all health benefits due me.
I have reviewed the following treatment plans and fees. I agree to be responsible for all
charges for dental services and materials not paid by my dental benefit plan, unless the
treating dentist or dental practice has a contractual agreement with my plan prohibiting
all or a portion of such charges. To the extent permitted under applicable law, I
authorize release of any information relating to this claim. This "Signature of File" will be valid from this date and shall expire in one year. A photocopy of this document may act as an original.

I, the patient or duly authorized representative of the patient, accept full
responsibility for all fees regardless of dental insurance coverage.