Financial Policy
Thank you for choosing us as your dental care provider. We are committed to your treatment being successful.
Please understand that payment of your bill is considered part of your treatment. The following is a statement of
our financial policy which we require that you read and sign prior to any treatment. It is our hope that this policy will
facilitate open communication between us and help avoid potential misunderstandings, allowing you to always
make the best choices related to your care.
Insurance
Please remember your insurance policy is a contract between you and your insurance company. We are not a party to that contract. As a courtesy to you, our office provides certain services, including a pre-treatment estimate which we send to the insurance company at your request. It is physically impossible for us to have the knowledge and keep track of every aspect of your insurance. It is up to you to contact your insurance company and inquire as to what benefits your employer has purchased for you. If you have any questions concerning the pre-treatment
estimate and/or fees for service, it is your responsibility to have these answered prior to treatment to minimize any confusion on your behalf.
Please be aware some or perhaps all of the services provided may or may not be covered by your insurance policy. Any balance is your responsibility whether or not your insurance company pays any portion.
Payment
Understand that regardless of any insurance status, you are responsible for the balance due on your account. You are responsible for any and all professional services rendered. This includes but is not limited to: dental fees, surgical procedures, tests, office procedures, medications and also any other services not directly provided by the dentist.
FULL PAYMENT is due at the time of service. If insurance benefits apply, ESTIMATED PATIENT CO-PAYMENTS and DEDUCTIBLES are due at the time of service, unless other arrangements are made. UNPAID BALANCE over 90 days old will be subject to a monthly interest of 1.0% (APR 12%). If payment is delinquent, the patient will be responsible for payment of collection, attorney’s fees, and court costs associated with the recovery of the monies due on the account.
Appointment Attendance
Financial Policy
Please help us maintain the highest quality of care by keeping scheduled appointments. Your appointment time is
reserved especially for you. We appreciate your understanding and consideration of our policy.
1. We request 48 hours notice by phone call to make any changes to your appointment. Changing an appointment without 48 hours notice or missing an appointment without notice will result in an assessed fee. Assessed fees are $60 for hygiene appointments per hour and $90 for appointments scheduled with the doctors.
2. After two (2) missed appointments we may require a deposit of up to 100% of your service fee, in order to reserve any further appointments.
3. After three or more failed appointments you may risk being dismissed from the practice or be placed on a short-notice scheduling list.
4. If you arrive more than 10 minutes late for your appointment you may have to be rescheduled. This could result in a missed appointment assessed fee.
5. If you are concerned you will be late to an appointment, please contact us! We can then advise whether or not
there will be sufficient time to reschedule your appointment.
Missed/canceled appointments or other unusual attendance problems are documented in your medical record. If
you are discharged due to attendance issues, re-admission to Haven Dental PDX will require approval by the
owner.
Thank you for choosing us as your dental care provider. We are committed to your treatment being successful.Please understand that payment of your bill is considered part of your treatment. The following is a statement ofour financial policy which we require that you read and sign prior to any treatment. It is our hope that this policy willfacilitate open communication between us and help avoid potential misunderstandings, allowing you to alwaysmake the best choices related to your care.