Written Financial Policy
Cancellations and Missed Appointments
Your appointment time is reserved specifically for you and for you only. Because of this, missed appointments or late cancellations are extremely detrimental to our day. As a result, we request at least 48 hours advanced notice if you will not be able to make your appointment. A fee of $75 is charged for patients who miss or cancel hygiene appointments without 48-hour notice, and $200 fee will be applied towards those who miss or cancel appointments with the Dentist. For patients with more than two missed appointments, a credit card deposit may be required to secure your next appointment. Repeated missed appointments or late cancellations may result in fees or dismissal as a patient.
Thank you for choosing Shoreline Dental Studio. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.
You can choose from the following payment options: Cash, Check, Visa, MasterCard, American Express or Discover Card.
We offer a 3% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $1000 or more.
Convenient Monthly Payment Options are available from Care Credit Healthcare Credit Card interest-free for up to 6 months. Additional fees and increased APR are available for patients needing extended monthly payments and can utilize Care Credit and their terms to pay for services rendered. Should a payment be missed CareCredit will charge the interest immediately per their terms and conditions.
We allow patients to pay for treatment rendered over time (up to 4 monthly payments interest free for treatment expenses/co-pays below $1,000), and 10 monthly payments at 9% APR for Invisalign Treatment only.
No annual fees or pre-payment penalties.
Please note: Shoreline Dental Studio requires payment prior to the completion of your treatment.
For single crown appointments, half can be paid at initial appointment and the second half at the time of the seat appointment. For larger, more comprehensive treatment plans of $1000.00 or more, a $250 deposit is required to reserve your initial treatment appointment. Additional deposits may be applicable at Shoreline Dental Studio’s discretion and will be reviewed with you if applicable.
We charge 5% interest on all past due accounts.
Shoreline Dental Studio charges $35 for returned checks.
We value your time greatly. We reserve appointment times especially for you, and we’ll do everything in our power to be respectful of your time constraints. We ask that our patients do the same for us.
Insurance Assignment of Benefits
I understand that services rendered to me by Shoreline Dental Studio are my financial responsibility and that the provider will bill my insurance company as a courtesy. I authorize my insurance company to pay my benefits directly to Shoreline Dental Studio and I understand that I will be fully responsible for any outstanding balance on my account. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY.
This payment will not exceed my indebtedness to the above-mentioned assignee and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment. I have been given the opportunity to pay my estimated deductible and co-insurance at
the time of service.
I have chosen to assign the benefits, knowing that the claim must be paid within all state or federal prompt payment guidelines. I will provide all relevant and accurate information to facilitate the prompt payment of the claim by my Insurance Company.
I authorize the provider to release any information necessary to adjudicate the claim, and understand that there may be associated costs for providing information beyond what is necessary for the adjudication of a clean claim.
I also understand that should my insurance company send payment to me, I will forward the payment to Shoreline Dental Studio within 48 hours. I agree that if I fail to send the
payment to the Provider and they are forced to proceed with the collections process; I will be responsible for any cost incurred by the office to retrieve their monies. In the
event patient receives any check, draft or other payment subject to this agreement, I will immediately deliver said check, draft or payment to provider. Any violations of this
agreement will, at provider’s election, terminate patient charge privileges with provider and bring any balance owed by patient to provider immediately due and payable.
To avoid this additional cost and inconvenience, should the insurance company forward payment to me, I authorize Shoreline Dental Studio to facilitate payment utilizing the credit card number on file to resolve the balance. A photocopy of this Assignment shall be considered as effective and valid as the original.
I authorize the provider to initiate a complaint or file appeal to the insurance commissioner or any payer authority for any reason on my behalf and I personally will be active in the resolution of claims delay or unjustified reductions or denials.
For those dental insurance, we know the insurance companies do not always process claims within the legal guidelines. When that happens we will be happy to file a complaint to the Insurance Commissioner to get your benefits released.
To Whom It May Concern:
My provider filed the attached claim form with you over thirty days ago; it has not been paid or denied. It is my understanding that there are state prompt payment laws and/or guidelines that monitor commercial insurance carriers and these laws and/or guidelines are regulated by the State Insurance Department. Benefits were assigned to and as of todays date, payment has not been received. I am responsible for payment of this bill. Please accept this letter as a formal written complaint against the Insurance Company.