Our office wants all of our patients to comfortably afford & have the opportunity to decide
which payment options best suit your dental and medical needs. Our office will gladly work
with you to help get the maximum benefit available to you.
Most insurance plans do not cover 100% of all procedures. We will estimate your insurance coverage as closely as possible until we actually receive the payment from the insurance company. An estimate is not a guarantee of insurance payment. We will assist you in dealing with your insurance as a courtesy, but the ultimate responsibility lies with you to follow up with your insurance in receiving payment. If applicable, you will be asked to pay your deductible, copayment, and all or a portion of your coinsurance on the day the service is rendered. Our estimates are subject to final approval by your insurance and could therefore change the amount due to our office. Any Secondary insurance shall be filed as primary insurance.
By signing this form, you hereby authorize and direct any insurance payment for services rendered otherwise payable to you to be paid to Sunny Dental Care. If you receive any reimbursement payments from your insurance for services rendered, you agree to pay Sunny Dental Care the full amount of the reimbursement and/or the remaining balance for services rendered. Sunny Dental Care is entitled to keep the full amount of your reimbursement as that will be used towards the billable amount of services rendered. You understand that your credit can be adversely affected should you not pay Sunny Dental the reimbursement payment difference or remaining balance.
Any balance must be paid off on the last visit of dental procedure(s).
After 60 days the remaining balance (should there be any) will be due in full by you. Should any delinquent balances remain beyond 60 days with no attempt on your end to pay in full or with no payment plan in place, you understand that your credit can be adversely affected as reporting to collection agencies and lawyers will be pursued.
PAYMENT OPTIONS AND DISCOUNT
Our office accepts Visa, MasterCard, American Express and Discover credit cards, cash, check, Care Credit and Flexible spending card.
- Pre-payment of Treatment in Full 2% off on Credit Card payment and 5% off on cash payment.
- Pre-Authorized Credit Card monthly payments: If you prefer to pay out larger portions of treatment on your credit card on a regular monthly basis, we accommodate you by having you sign a monthly authorization form. Once per month your card will be charged the allotted monthly amount. A down payment will be required at the time the agreement is made.
- Senior Citizens (Age 60 and over) Discount: As a courtesy to anyone 60 years old and older we will gladly discount 10% of all procedure if services are paid in full at the time of treatment.
Patient/ Responsible Party’s Signature:
Use your mouse cursor or the tip of your finger to sign below