Patient Payment for Services Information
Dear Patient:Thank you for choosing Powell Family Dentistry, we strive to provide high-quality care at a reasonable cost. We need you to understand and agree to our Patient Payment for Services to achieve this goal. Powell Family Dentistry does not provide free care. Patient payment is due at the time of service. Our service fees are reviewed annually and may be increased when necessary.
Introductions
Our mission is to improve access to dental care for the residents of eastern Tennessee. Our practice depends upon reimbursement from patients for the costs incurred in their care. Therefore, the financial responsibility on the part of each patient must be determined before treatment can be rendered. All dental services are charged directly to the patient, and the patient is personally responsible for payment of all dental services, even if the patient carries dental insurance. This office will, as a courtesy, help prepare the patient’s insurance forms and may assist in making collections from dental insurance companies and will credit any collections from insurance to the patient’s account.
Emergency Dental Care
Powell Family Dentistry provides emergency services for patients seeking same-day treatment of urgent dental needs. Emergency treatment is limited to services to relieve pain and prevent infection. We understand you may or may/not have insurance. All emergency and any dental services performed without previous financial arrangements must be paid for in cash when services are rendered.
Patients Without Insurance
Payment is due at the beginning of each appointment; however, in some cases we will be able to assist you in making payment arrangements for major or staged treatment based upon the type of services planned and the department in which you are seen. The office team will assist you in making these arrangements, but they must be made before treatment begins. For your convenience, we accept multiple forms of payment, including cash, personal check, flexible spending account debit cards, and major credit cards (i.e., MasterCard, Visa, Discover). We also offer payment plan options through a third-party vendor, Cherry Technologies.**Financial Disclaimer**Payment for services rendered will be due at the time of service.* I understand that I am responsible for all charges incurred during the course of my treatment.* I agree to pay for services when I check-in for my scheduled appointment* I understand that any balances must be paid within 60 days to Powell Family Dentistry.
Patients With Insurance
Powell Family Dentistry accepts most commercial dental insurance plans and TennCare. Most dental insurance carriers set deductibles, co-insurance payments, exclusions, and other coverage limitations. As a courtesy, members of the business office team will process pre-estimates and pre-authorizations and assist you when possible, but it is your responsibility to know your benefits and coverage limits. You may be required to pay part or all your treatment costs if our providers are not contracted (or “out-of-network”) with your dental or medical insurance. The business office team members will help you with your questions about treatment fees and insurance.You are expected to pay for any services that your carrier does not cover on the day you receive treatment; however, in some cases we will be able to assist you in making payment arrangements for major or staged treatment based upon the type of services planned.**Financial Disclaimer**As consistent with applicable laws and the terms of your dental insurance or other dental plan coverage:* I understand that I am responsible for all charges incurred during the course of my treatment.* The insurance portion of the treatment plan is an estimate and not a guarantee of coverage.* I agree to pay for services when I check-in for my scheduled appointment* If your insurance carrier pays less than the anticipated amount, you will be responsible for the unpaid balance.* I understand that I may be responsible for any unpaid balance for the procedures that are performed.* I understand that any balances must be paid within 60 days to Powell Family Dentistry.
Patients With TennCare
Patients must provide a valid ID, eligibility information, a current address, and a valid TennCare card at each appointment to verify coverage. If we cannot confirm that your coverage is active on a particular date, you must pay in full for the visit or reschedule your appointment. You may decide that you want to receive services that TennCare or Medicare does not cover. If so, you will be asked to sign a Medicare Advance Beneficiary Notice (ABN) or a waiver stating that you will be financially responsible for the specific services that are not covered.PATIENT APPOINTMENT CHECK-IN REQUIREMENTPatients must personally check in with our front desk team prior to every appointment to review the status of their account and pay any amount due before receiving treatment.
Financing with Cherry
If you are interested in financing your dental treatment instead of paying up front, we accept third party financing through
Cherry. Cherry provides patients with many choices for financing. An application for Cherry can be found on their
website. Please let us know if you have any questions.
Aknowledgement
At the time of your initial appointment, you will be required to electronically sign a form stating the following:“I understand and agree to accept my responsibility to pay for services I receive as a patient of Powell Family Dentistry, per this agreement. I also understand that if I do not meet this responsibility, I will be referred to a collection agency and dismissed as a patient of Powell Family Dentistry.”Patients who do not sign the acknowledgment are ineligible for services at Powell Family Dentistry.
