Financial Policy Financial Policy Patients without Insurance Coverage Payment in full is expected at the time of service. We offer a 5% discount to patients who pay in full at the time of service with either check or cash; debit cards do not receive the discount. We can make arrangements for short term payments if necessary, but this needs to be asked for and arranged prior to the services being performed. Payment plans will be set up with ½ of the treatment costs being paid at the time of service and the rest split in monthly payments over the next 2 months. Patients on payment plans are required to keep a debit or credit card on file for automatic processing of payments each month. All balances over 90 days will be subject to a service fee. Contracted Insurances We will bill your insurance for you on your date of service. All out of pocket co-insurance estimates must be paid for at the time of service. Once your claim is processed by your insurance, any additional amounts, deductibles, or non-covered services will be due upon receipt. All balances over 90 days will be subject to a service fee. Patients on payment plans are required to keep a debit or credit card on file for automatic processing of payments each month. Non-Contracted Insurances As a courtesy we will bill your primary insurance for you; however you are responsible for full payment of your account. We expect that you pay your account in full at the time of service; we will have your insurance company reimburse you for the services. Workers Compensation Claims If you are seeing our office for an injury that occurred during employment, please notify our front office that the injury is “work related” so that we can fill out the appropriate paperwork. If your insurance carrier or employer denies the claim, you will be held financially responsible for the charges. Services provided to minors A “minor” is defined as someone less than 18 years of age. We realize there may be an arrangement regarding who is responsible for paying medical services on a minor. However, it is our policy that the parent/guardian who requests medical care for the minor be the financially responsible party. Students/Short term Patients If you would like we can send your statements and any correspondence to an alternate address;however be advised that if you are over 18 you will still be held financially responsible for any charges incurred. You will also be required to pay any co-pays at the time of service. Collection Accounts and No Show Fees There will be a $60.00 “No-Show/Less than 24 hour” fee for all appointments that are no shows or we have not been notified 24 hours prior to the appointment. After your 3rd “No-show/Less than 24 hour” appointment you will be dismissed from the office. NSF checks will be charged $35.00. If your account is turned to collections due to non-payment it will be referred to Transworld Systems. In addition, BlueSky Dental reserves the right to terminate the doctor-patient relationship if your account is sent to collections. Thank you for taking the time to review this information. Should you have questions or need to arrange a payment plan, please contact our Office Manager at 208-882-9111, or jsouthwick@blueskydentistry.com. Please Sign and DateName* Date* MM slash DD slash YYYY Signature* Δ