Rolling Hills Dental Clinic is dedicated to provide quality dental care in a friendly and caring environment that encourages patient participation in the treatment process.  We are committed to providing our patients with the newest techniques in preventive, restorative and cosmetic care.  In addition, we are also dedicated to making top-quality care as cost-effective as possible.  To assist you with your healthcare investment, we provide the following payment options:

Payment Options:

Payment is due at the time of treatment.  For your convenience, we offer the following

financial arrangements

*  Cash or check

*  Mastercard and Visa  (there is a 3% fee for credit cards, but that does not apply to debit cards)

*  Care Credit

Returned Check Fee of $30.00 will be charged for insufficient funds.  Also, a $3.00 monthly billing charge will apply to accounts over 30 days.  All account balances over 60 days will be assessed a handling charge of 1.5% a month (18%APR).  All accounts over 90 days will be transferred to a collection company or legal system.  At that time, all costs of collection, including attorney and legal fees will be added to your account balance.

Insurance Policy:

Our goal is to maximize your insurance benefits and make any remaining balance easily affordable.  Please be prepared to show your insurance card at the time of your visit.  If the patient has any insurance changes, it is the patient’s/guarantor’s responsibility to provide the new information.  If this information is not provided at the time of service, the patient/guarantor will be responsible for all the charges incurred.  I understand my dental insurance is a contract between the insurance carrier and myself, not between Rolling Hills Dental Clinic and the insurance carrier.  Our office will gladly submit your insurance to your primary and/or secondary insurance as a courtesy.  The patient/guarantor is responsible for their estimated portion and additional fees at the time of service.  Please be aware that some insurance companies may not cover all service performed in our office.  If for some unforeseen reason your insurance payment is not paid within 30 days, the patient/guarantor is responsible for the charges that are denied or unpaid by your insurance.  It is the patient or the patient’s representative to understand their insurance coverage prior to their appointment.

Note:  Most insurance companies will not pay for composites (white fillings) on posterior teeth.  Instead, they pay their allowance for an amalgam (silver filling).  You are responsible for the difference.  Please keep this in mind as Dr. Becker does not do amalgam fillings.

Authorization:  I consent to your use and disclosure of my PHI (Protected Health Information) to carry out payment activities in connection with my dental claims.  I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to Rolling Hills Dental Clinic.

Cancellation Policy:

If you are unable to keep an appointment, we ask that you kindly provide us with a minimum of 24 hours notice.  This courtesy on your part will make it possible to give your appointment to another patient who needs to see the dentist or hygienist.

Missed Appointment Fee:

A missed appointment fee may be charged to any patient who does not notify our office within a minimum of 24 hours to cancel or reschedule their appointment. If one or more appointments are missed or cancelled without adequate notice, we may reserve the right to not reschedule that appointment/future appointments.

I have read and agree to the policies.