Читать книгу Managing Finances: Guidelines for Practice Success - American Dental Association - Страница 9

• Sample Financial Policy Statement, p.6

• “Refunds and Discounts,” ADA GPS^TM on “Managing Patients,” Patient Relations https://success.ada.org/en/practice/guidelines-for-practice-success/managing-patients-patient-relations/refunds-and-discounts

SAMPLE FINANCIAL POLICY STATEMENT

NOTE: This form may or may not satisfy applicable state law. It is imperative that parties relying on this form consult with their legal counsel to modify this form as necessary to comply with applicable law.

Payment for services, including deductibles and copayments, are due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or credit cards. Any arrangements for third-party financing must be made before starting treatment.

[Practice name] accepts most dental benefit plans. We are happy to submit the claims necessary to see that you receive your benefits. The dental benefit contract is an agreement between you and the dental benefit company. You are ultimately responsible for all charges. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed.

In order to maximize your benefits and because plans differ from carrier to carrier, and from policy to policy, our office may refer you to your carrier or your employer’s benefits coordinator for assistance in understanding your plan. Please note that your dental plan is intended to cover some but not all dental care costs, and not all services are covered by your plan. You are responsible for payment of all services regardless of the payable benefit.

Checks that are returned to our office from your financial institution are subject to a $25 returned check fee. This fee covers the processing fees that are charged to our office. We would be happy to discuss our charges and how they relate to your particular situation.

Please indicate your understanding and acceptance of these financial policies by signing below.

Patient’s name		Date
Patient, guardian or guarantor signature		Date
Witness name		Date

© ADA 2015. Reproduction of this material by ADA member dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written approval of the American Dental Association. This material is educational only, does not constitute legal advice, and may not satisfy applicable state law. Changes in applicable laws or regulations may require revision. Contact a qualified lawyer or professional for legal or professional advice.