FINANCIAL POLICY
Unless another financial option is PRE-ARRANGED, payment is due in full the day of treatment, or on pre-op visits for extensive treatment appointments. Should a patient have dental insurance with assignment to Dr. Tran, the estimated patient portion will be the amount due. Any discrepancies with insurance eligibility and/or benefits will be the patient’s responsibility to pay the balance. Insurance payments without assignment will be sent to the insured with payment due in full. The insurance plan is YOURS, as a courtesy, our office will help you file any insurance claims. Hence, it is your responsibility to inform us of any changes prior to your dental visits. In addition, we have a 48 hrs cancellation policy. We reserve the right to charge for any broken, no show and cancelled appointments without a minimum notice of 48 hrs.
Payment Options
- For your convenience we accept Cash, Visa, MasterCard, American Express, Discover, PayPal & Check.
- We also offer short and long-term financing options. (Interest-free options may apply- Care Credit)
For Patients with Dental Insurance
Dental insurance plans often pay less than the actual fee for service, therefore the patient or Guarantor, is the responsible party for all dental services provided. Dental insurance in most cases is only a benefit with limitations and should not be expected to take care of all costs. Your dental benefits and how they relate to your specific needs will be explained to you, as best as we can, during your appointment. Please ask us if you have any questions.
Finance Charge and Fees
- Balances in excess of 60 days are subject to a finance charge of 1.5% per month (18% annual).
- Failure to make a payment for more than 90 days may result in the patient account being turned over to a collection agency. Patient and/or legal guardian will be responsible for any collection fees involved.
- Returned checks are subject to a minimum of $40 accounting fee
AUTHORIZATION AND CONSENT
General Consent to Treatment
I agree and consent to a dental examination and x-rays by Dr. Tran and his associates. I understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. Also, I acknowledge that there are no guarantees, expressed or implied, as to the result of any procedure or dental treatment preformed.
Release of Information
I authorize Dr. Tran to release any information regarding my dental/medical history, diagnosis and/or treatment to third party payors and/or other health professionals.
Assignment of Insurance Benefits
I authorize and request my insurance company to pay my benefits directly to Dr. Tran, Mangrove Bay Dentistry P. A.
Photography Release
I authorize Dr. Tran and/or his associates to take intra-oral and extra-oral photographs of me to help me better understand my current dental conditions and possible treatment options.
I authorize Dr. Tran to show dental photographs and x-rays, excluding self-portraits, to other patients to better explain their treatment options with the understanding that personal information (ie: name) will NOT be disclosed.
I understand and will comply with the office Appointment Policy.
I understand and will comply with the office Financial Policy.
I understand and agree to the General Consent to Treatment.
I authorize the Release of Information.