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Financial and Office Policies
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At Frisco Elm Dental, we believe that you deserve the best care. That’s why we always present you with the best dental solution possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental benefits but some don’t. If you have dental benefits, congratulations! You are very fortunate. Here are some important things you should know:

* A specific amount of time is reserved especially for you. We strongly encourage all patients to keep their appointments. If you must change your appointment, you promise to give us ATLEAST 48 HOURS NOTICE(outside of emergencies), in order to avoid a $25 CANCELLATION FEE.
* Frisco Elm Dental requires payment in full for your portion at the time of service. We accept MasterCard, Visa, American Express, Discover, and cash. We do not accept checks. If you are in need of an extended finance option, we also work with CareCredit, who offers 3, 6, 12 or 18 month “same as cash” or longer terms with an interest bearing revolving charge designed to meet your treatment plan needs on approved credit.
* In the event of an emergency after regular business hours a $55 emergency fee will be charged for established patients in addition to the necessary treatment fees. Patients who are not established in the practice will be charged $125 after hour’s emergency fee.
* Documenting Treatment: Frisco Elm Dental may document my treatment using x-rays, photos and/or videos. I hereby grant Frisco Elm Dental the right to edit, use, and re-use these. I release Frisco Elm Dental and its employees from all claims, demands, and liabilities whatsoever in connection with the above.
* Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits please contact your employer or insurance company directly. Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you.
* We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or require our office to accept a reduced fee for service). This means that we work with literally thousands of companies. Although we can maintain computerized histories of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your insurance benefit, we will be happy to file a “pre-treatment authorization” with your insurance company prior to treatment. Keep in mind this is not a guarantee of coverage. This does delay treatment but will give you the exact out of pocket figures you may require.
* We will bill your insurance as a courtesy. If insurance does not pay within 90 days, Frisco Elm Dental reserves the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.
* We require you to sign this form and/ or any necessary assignment documents that may be require by your insurance company. This instructs your insurance company to make payment directly to our office.
* Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We perform routine insurance billing procedures upon verification of coverage. However, if your claim is denied, you will be responsible for paying the full amount at that time.

* I have read and understand the above terms and conditions. I authorize my insurance company to pay for my dental benefits directly to Dr Vidya Suri/Frisco Elm Dental.

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