29 Palms Dental Group, An Nguyen, DDS, MS
73666 Joshua Dr Twenty nine Palms , CA 92277
Smile29Dental@live.com
Financial Agreement
This financial agreement is indicative of our respect for your right to know ahead of time what our expectations are in the area of finances and our office policies. If you have any questions or concerns about our Financial Agreement, please do not hesitate to ask.
Payment Policy:Treatment is to be Paid In Full at the time services are rendered unless other arrangements have been discussed and finalized. All payment arrangements are to be discussed and agreed by one of the current office Finance Coordinators.
We accept Cash, Checks, most Major Credit Cards, Care Credit and Lending Stone.
Payment in full is DUE and EXPECTED at the time services are rendered.
Treatment Cost Estimates:Dental Insurance is a benefit used to assist you, not to dictate necessary treatment. You MUST provide us with a copy of your insurance card(s) and a valid Identification/License card to verify your dental insurance coverage(s) and file your claim. All charges incurred for any treatment that is provided are your responsibility regardless of your insurance coverage. An ESTIMATE of the amount due from you will be calculated when the appointment is scheduled. As we work with you to reach your optimum oral health, we do require that the estimated co-payment for treatment be paid at the time of service. When estimates involve dental insurance benefit coverage, please be advised that no insurance estimate can be guaranteed to be 100% accurate. Completing insurance forms is a courtesy we extend for your convenience in an effort to save you time and facilitate payment to our practice from your insurance company. We will accept an Assignment of Benefits from your insurance company (if they allow it) however it is important to understand that the agreement regarding your dental benefits is between you, your employer and your insurance company.Your Insurance company makes a final determination once treatment is completed and the claim is submitted.You are responsible for OUR FEES and not what your insurance company allows or thinks is “Usual, customary and reasonable” all of which vary from one insurance company to another. We are happy to assist you but ultimately it is your responsibility to resolve any type of dispute over payments made or not made by your insurance company to our practice.
Minors: Minors(patients under age 18) must be accompanied by a parent or guardian at all times. The parent/guardian accompanying the minor to the appointment is responsible for any payment at time of service.For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with Parent and/or legal guardian. The signature at the completion of this Financial Agreement does hereby authorize 29 Palms Dental Group, An Nguyen, DDS, MS to examine, clean, take x-ray(s), use anesthetics and provide dental treatment on a minor as considered necessary by Dr. An Nguyen. .
Broken Appointments: Once an appointment has been made, please remember that this time has been reserved specifically for you. We reserve the right to charge a fee for all cancelled (within 24 hours prior) or missed appointments without written or verbal notice. We do understand unexpected events and emergencies can happen.
Delinquent Accounts & Collection Fees:
Checks that are returned to our office from your financial institution are subject to a Returned Check Fee. This fee will cover the processing fees that are charged to our office.
In the event you fail to pay the account balances as agreed in this Financial Agreement, 29 Palms Dental Group, An Nguyen, DDS, MS may report your account to credit rating bureaus or to a collection agency and/or take legal action against the Undersigned/Responsible Party for Full Payment, including but not limited to all related reasonable attorney’s fees, collection and/or court costs. That includes ALL collection costs incurred by the dental office of 29 Palms Dental Group, An Nguyen, DDS, MS.
Authorization: