OFFICE POLICY – INSURANCE
The following is a description of our office policy concerning orthodontic insurance. We will do everything possible to maximize your benefits.

Our financial contract is a two party agreement between our office and the patient (or patient’s parents). It is the sole responsibility of the patient to keep the account current as to the monthly terms stated in the contract regardless of his/her insurance benefits. The amount of reimbursement by an insurance company always is governed by the size or cost of the premiums paid. Therefore, there may be a wide range in benefits, even by the same insurance company.

All services are charged directly to the patient; and patients are personally responsible for payment of charges incurred and their payment schedule will be placed on automatic draft from checking account, savings account or credit card. Your benefits will be directed and accepted by our office to apply to your account. This will enable your account to accrue, thus fulfilling your financial obligation sooner. Your automatic draft will continue each month regardless of insurance payments. Your draft will be terminated as soon as your original financial obligation has been fulfilled. It must be understood that if the insurance company’s total payments do not equal the expected benefits, the responsible party will need to make-up any differences.
This action is necessitated by the massive amount of time involved, making phone calls, or follow up information and completing continuation of treatment forms, etc. Rather than pass this additional cost to the patients we have opted to require all payments be directed ot our office.
   
 
   
 
Once it is determined a person needs treatment, they will be presented with this form showing them the options for paying for their care.
   
 
PAYMENT OPTIONS
Date  ___________
 
 
Patient Name __________________________
   
 
The total fee for orthodontic treatment is
$ _______
   
   _______  insurance if applicable
   
$ _______
   
 
Treatment times differ from patient to patient. These payment options do not correspond to the estimated treatment time but re merely provided for our convenience.
   
 

OPTION A: Springstone Patient Financing

  • No initial payment (no down payment)
  • No interest plan or extended plan, start 5.99 APR
  • Significant tax advantage
  • Prepayments can be made anytime
  • Fast, confidential service by phone or online at SpringStonePlan.com good credit standing required
   
 

OPTION B: Payment in Full

  • A bookkeeping courtesy of 5% or $ ______ is given for direct payment in full at start of treatment by cash or check resulting in a onetime payment of $ __________.

OPTION C: Office Contractual Agreement

$______ is the initial payment to the office due when treatment begins. The balance may be paid through the following option: ______ monthly payments of $ ______.

We offer our in house contract at 0% finance charge, therefore this option requires an Automatic Draft through:

  • Checking Account
  • Savings Account
  • Credit Card on file