Payment is required at the time services are rendered. This includes applicable coinsurance and copayments. We accept cash, personal checks (in-state only), Care Credit, Visa, MasterCard, and AMEX.
RETURNED CHECKS: $25.00 service charge.
REQUEST FOR RECORDS: $25.00 fee due at time of request.
DUPLICATION OF X-RAYS: $10.00 due at time of request.
GA 3300 FORMS: $6.00 due at time of request.
OUTSTANDING BALANCES: Balances 60+ days must be paid in full before scheduling. Late payment charge of 5% per month applies.
INSURANCE: As a courtesy we bill participating insurance companies. You are expected to pay deductible and copayments at time of service. If insurance hasn't paid within 60 days, you pay the balance in full.
REFUNDS: Credits under $20 retained on account. $20+ refunded on next billing cycle.
MISSED APPOINTMENTS: 48 hours notice required. $50.00 charge for missed or last-minute cancellations. Habitual cancellations will result in discharge from the practice.
I have read and understand the financial policy. I agree to assign insurance benefits payable to Smiles for Kids whenever necessary.
