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Dr. Jurina Smida and staff would like to welcome you to our office. *
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We offer the following financial policy to eliminate confusion and misunderstanding about fees and how we ask you to handle your account with us.
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In general, we prefer that your fee be paid at the time we deliver your care. If arranged in advance,
other payment arrangements may be made. These payment arrangements are made individually based on the amount of the fee, duration
of the treatment and payment history. Please understand that payments may not be made available for all treatments. We will always
be clear about the fee and how we agree it will be paid before we ask you to commit to an appointment. We will always provide a written
and signed agreement outlining the fees and the payment arrangement.
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While we accept the direct assignment of benefits from your insurance carrier, we want to make sure that you understand that
all fees are ultimately your full responsibility. In many cases, patients are disappointed when their carrier fails to pay as
much as expected, so if you rely on an insurance contribution, please get a written guarantee from your carrier prior authorizing
your dental care. Should your insurance carrier fail to pay some or all of what is estimated, we will require you to handle the account
balance in full no later than 60 days after your care has been completed. |
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We accept cash, personal checks, major credit cards and automatic bank drafts as payment for fees in our office.
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Returned check policy: There is a $35.00 fee for all returned checks. If we have a check returned more than twice,
we will not accept checks form you.
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Cancellation of Appointments: We have reserved time on our schedule for your dental needs, please give
us 48 hours notice if you cannot keep your appointment. There will be a broken appointment service charge minimum of $95.00 per
hour for hygiene schedule and minimum of $250.00 per hour for Dr. Smida’s schedule patients applied to your account.
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Finance charge: A finance charge will be added on all accounts beginning 30 days from the billing date at the
rate of 1.5% per month, which is an annual percentage of 18% on the unpaid balance after deducting payments and credits.
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PLEASE READ THE ABOVE INFORMATION AND SIGN BELOW.
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THANK YOU FOR YOUR COOPERATION!..!
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