IMPORTANT: A WORD ABOUT OUR PAYMENT POLICY
To help control escalating healthcare costs we do not routinely send monthly billing statements to our patients. As a condition of your treatment by this office, you are asked to pay your patient portion at the time of service. We accept cash, checks, debit & credit cards. Upon approval, monthly payments are accepted through our financing options. I understand that the estimated fees quoted for dental care can only be extended for a period of twelve months from the date of the patient’s consultation.
Oasis Dental Spa provides dental care to children of all ages. As a parent/guardian, you are accepting responsibility for your child’s conduct while in our office. Please do not leave your child unattended. If you are a parent or stepparent of a minor child, you understand that you are responsible for billing/collecting from the non-custodial or financially responsible parent of your minor child. Oasis Dental Spa cannot act as an agent on you or your child’s behalf to collect or enforce court ordered payments or responsibilities. Minors must be accompanied by an adult who can be accessible in case of unexpected changes in treatment are needed during the appointment. In the case that the parent/guardian is unable to accompany the minor, the attending adult must bring written consent for treatment and disclosure for the authorized person, and must be signed, by parent/guardian.
Patients who carry dental insurance understand that while we do accept assignment of benefits from your insurance company, all dental services provided are charged directly to you the patient and that you are personally responsible for payment of said services. As a courtesy, we will file claims on your behalf with your insurance company. However, we must emphasize that we provide this service as a courtesy. Oasis Dental Spa does accept responsibility for collecting payment on your claim. If you have questions regarding your claim, please contact our office or your insurance company. Oasis Dental Spa does not participate in any HMO plans, however, Oasis Dental Spa does participate in a select number of PPO, “Group”, or “Network” plans. It is your responsibility to access “in-network” providers. Failure to access “in-network” providers may result in reduced benefits. Oasis Dental Spa will not be liable for reduction in benefits, payment, or denial of claims. If you have questions regarding your insurance coverage, please contact your insurance company.
Balances older than 30 days will be subject to a $10 monthly late charge unless previously written financial arrangements are made and are current. Appointments must be cancelled 24-hour (1 business day) prior to the appointment date to avoid a “Missed Appointment” charge of $25 on your account. Appointments longer than 1 hour will be subject to a $40 balance. Late cancellations could be accepted in “emergency” situations. Repeated and/or chronic cancellations may be assessed a cancellation fee of $25, $40 or $60. Please notify us immediately when you are unable to attend your scheduled appointment time.
If charges incurred at Oasis Dental Spa have been turned over to a collection agency, you will be asked to pay cash for all services and supplies before you receive them. Oasis Dental Spa may decide to terminate our physician-patient relationship with you due to non-payment. If the professional relationship is terminated, you will receive written notification. Emergency services only, will be provided for thirty (30) days after termination.
If Oasis Dental Spa has been included in your bankruptcy, you will be asked to pay cash for all services and supplies before you receive them.
If at any time you need assistance with your bill or insurance please contact your account manager: Lori Mansfield
In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) working days of billing if credit shall be extended.
I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof.
I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit were instituted hereunder.
I grant my permission to you or your assignee, to contact me to discuss matters related to this form.
I have read and understand the above conditions of treatment and payment and agree to their content. I authorize Oasis Dental Spa to release all necessary information to my insurance company for the purpose of payment, and authorize assignment of said benefits.