Children's Dental Center of Madison, S.C.
I understand that the information I have given is correct to the best of my knowledge and that it is my responsibility to inform this office of any changes.
Children's Dental Center Financial Relationship
Thank you for choosing Children's Dental Center to serve your family's dental needs. Our office is dedicated to providing the highest quality of dental care possible for every patient. The following is a statement of our financial relationship with all of our families. Please review and let us know if you have any questions.
For your convenience we accept cash, personal checks, debit cards, all major credit cards, and Care Credit financing. You are welcome to use your Flex Spending or Health Savings Account, as applicable.
Non-Insured Patients: I understand that if I DO NOT have insurance coverage I select to be self-pay. Payment is due on the day that dental services are performed. A 5% discount is given when the full amount due is paid using a check or cash payment on the day of service.
Insured Patients: I understand that if I DO HAVE dental insurance, Children's Dental Center will file my insurance as a courtesy. There is no guarantee of coverage. Patient portions are an estimate and not a guarantee of exact payment. The patient is responsible for the estimated portion of the procedures and deductibles at the time of service. Once your insurance company has paid, you will be responsible for any balance that is remaining. If your insurance policy pays you directly, you are responsible for the amount they pay and your portion.
I understand that my insurance can be OUT OF NETWORK with my chosen provider. Procedures are quoted at standard fees and I am provided with an estimate of my out of pocket portion according to my insurance policy. This is not a guarantee of benefits and I accept responsibility for payment of services.
I understand that my insurance can be IN NETWORK but the benefits may not cover all services according to the estimate given. I am responsible for the deductible and my patient portion at the time services are rendered and any remaining balance after my insurance has paid.
Please understand that insurance is a contract between you (your employer) and your insurance company. If an insurance carrier has not paid us within 60 days of billing, any unpaid professional fees are due and payable in full from you.
All ESTIMATED fees are due at the time of service.
Payment Plan Options:
Third party financing through Care Credit is a form of payment we accept. They offer flexible financing options with more information at carecredit.com. We are happy to help you with the process.
Credit Card authorization for recurring charges is available when the treatment estimate exceeds $350 and your account remains in good standing with previous payments due. The services need to be paid in full in a total of four months or less. Any payment arrangements need to be worked out with our billing coordinator prior to the appointment.
I have read, understand and agree to all of the above. I have been given the opportunity to ask questions. If I have insurance, I hereby authorize my insurance company to pay my dental benefits directly to Children's Dental Center, and by signing the Health History, I authorize Children's Dental Center to release any medical information to my insurance company as needed to process my claim(s).
This statement has been edited to fit Children's Dental Center's needs and this document was not created by them.