ARIZONA PERIODONTICS
ANDREW E. DEEB, D.M.D.,M.S
801 N. WILMONT RD SUITE B2
TUCSON, AZ 85711
OFFICE FINANCIAL POLICY
The insurance contract between the patient and the insurance company: therefore, the patient is ultimately responsible for the bill, regardless of the insurance coverage determination. As a courtesy to our patients, we are happy to bill your primary insurance for you:
however the responsibility for payment remains with the patient or guardian.
- PATIENTS WITHOUT INSURANCE: Patients without insurance are required to pay the charges in full at the time services are rendered.
- ACCOUNT BALANCE: The balance on all accounts is due in full within 30 days regardless of insurance coverage or anticipated payments from other sources. In the event that payment for services is not made within 30 days of receipt of services, and interest charge of 5% per month will be added to the account (60% per year). Therefore, patients with insurance whose claims have not been paid within 30 days should contact their insurance company to determine the reason for delay of payment. Delinquents accounts will be referred for collections at the discretion of doctor, and a $100.00 charge will be assessed for all accounts sent to collections.
- CANCELLATION POLICY: Dental appointments cancelled without 24 hours’ notice or a “no show” will be subject to a $50.00 cancellation charge. If the appointment is for longer than an hour, then the fee will be based on $50.00 per hour allotted for that procedure. We will give you a call 48 hours in advance to remind you of your appointment and we ask that if a message is left you call to confirm your received the message. Please make sure if you move to give us your updated phone number and address so we can contact you.
- DUPLICATION AND TRANSFER OF RECORDS: When you get x-rays you are paying for the diagnosis of the x-rays and not the x-rays themselves. All original x-rays must remain in our office. If you are moving out of state or transferring to another office, your x-rays and records may be obtained for a $20.00 duplication fee per individual. A release form must be signed by the patient or guardian in our office. In the event an x-ray duplicate is needed for a specialist, one will be available free of charge for the patient to take for the consultation.
- PAYMENT OPTIONS: Personal checks, cash, money order, or Visa/Discover/MasterCard/American Express may be used for payment on your account. Financing plans are available that have many different payment options and some with “zero” interest depending on the amount the treatment. If you are interested in one of these plans, please ask the front desk for details.
ASSIGNMENT AND RELEASE: For individuals with insurance, your signature below hereby authorizes your insurance benefits to be paid directly to Andrew E. Deeb, D.M.D.. It also authorizes the doctor to release any information required for payment and processing of a claim. Please sign below to acknowledge your understanding of our office financial policy.
