Office Financial Policy

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Patient's Name                                                        Date

1.  We accept cash, check, debit cards, Mastercard, Visa, American Express, and Discover/Novus, with the balance cleared at the completion of treatment. Most endodontic therapy typically involves an initial exam, a subsequent one visit treatment appointment, and a six month follow-up exam.  Some cases involving trauma, inherent complexities, surgical care, or retreatment may require multiple visits.  When there is no insurance coverage, one half of the total quoted fee is required to initiate multiple visit therapy, with the second half due upon completion. The balance paid in full is required the day of treatment if one visit therapy is to be performed. 

2.  If the patient is covered by insurance, benefits are typically assigned payable to our office.  The amount not covered by insurance and any remaining deductible are required to initiate treatment.  If insurance benefits are to be made payable to the patient, processing of the claim will occur only after all balances are cleared.  If an approved insurance benefit reveals that an over payment has occurred by the patient, then a cash refund (office check) will be promptly issued our office directly to the patient. Any balance(s) prior to completion of treatment not covered by insurance are to be cleared by the patient.  We do not offer financing; however, treatment could be possibly "spread-out" over multiple visits/greater time, if so desired. Any collection fees, bank/civil charges or penalties are the patient's responsibility.

3.  Supplementary procedures may be necessary for diagnostic or prognosis reasons (i.e. biopsy or cytology) which may incur separate fees, in which you will be informed.  These procedures are usually billed directly to you by the laboratory and may also be covered under your medical insurance.

4.  Unique services including comprehensive diagnostic testing and follow-up, radiology, surgical, or restorative procedures may incur additional fees. Any exploratory or discovered facts about your case will be communicated in a case presentation or follow-up format as soon as known.  An attempt to provide a reasonable prognosis will be given in each case.

5.  We currently do not provide any Health Maintenance Organization (HMO) case processing.  Some Preferred Provider (PPO) agreements are accepted.  Please call our office to determine Provider status. Cases are usually accepted on a fee for service or a third party (indemnity) insurance basis.  Any written correspondence will be provided by our office to any insurer.

6. We're here to help...if you are not sure, please ask.

7.  Please indicate your method of payment:

___Cash  ___Check  ___Credit Card  ___Insurance  

___Need Discussion:________________________

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_Signature                                

Thank you,

Dr. Russin and Staff

This form may be printed/read/signed in advance and used as a part of the patient's chart.