Thank you for choosing Austin Dental of Roswell as your dental provider! We are dedicated to providing you with the
best possible care and we want you to completely understand our financial policy.
Payment
We are a fee-for-service dental provider and payment is expected at the time of treatment. Payment
includes any unmet deductible, co-payment and estimated charges not covered by your insurance company.
- Outstanding balances must be paid prior to any subsequent appointment.
- Overdue accounts may be subject to a 10% monthly fee.
- Accounts over 45 days delinquent may involve a collection agency, service fees and/or legal action.
- Returned checks will incur a $35 service charge.
- Payment Plan - We realize that there may be circumstances that could make payment difficult and assist you by
arranging a payment plan. Our payment plan policy will allow monthly payments not to exceed 4 months with a
minimum of $50 per month.
Please contact our office if you have questions or need to make a payment arrangement. All arrangements should be
made before your next scheduled appointment.
Insurance
Please remember that insurance is a contract between you and your insurance company and ultimately you are
responsible for payment in full. Keep in mind that we are not responsible for errors in estimations provided by your
insurance company.
As a courtesy, we file your primary dental insurance claim. We do not file secondary claims. It is
your responsibility to provide all current information and notify us of any changes in coverage. Austin Dental of
Roswell may be required to release information to your insurance company.
Cancellation Policy
We ask that you make every effort to keep your scheduled appointments. We reach out with reminders via text and
phone. Please reply to the text to confirm.
If you need to reschedule or cancel, we require a minimum of 48 hours’ notice. This allows us to make the
appointment available to another patient who needs to see Dr. Austin. For Monday appointments, please confirm or
cancel by 2:00 the prior Thursday.
A $50 fee will be charged for a missed appointment or when a patient fails to provide us with at least a 48-hour
notice of cancellation. After multiple cancellations or no-show appointments, a $100 deposit will be required to
book an appointment with the doctor.
Consent to Dental Care
I hereby request and authorize the dentist and clinical staff at Austin Dental of Roswell to perform any dental
procedures which, in their professional judgement, are necessary to diagnose and/or treat the area of concern. I
understand that there are risks and benefits with receiving dental treatment.
During the past decade, dental benefit plans have become an integral part of healthcare planning for many families.
Plans are made available to employees or members through companies, unions and associations and may vary
considerably from one plan to the next.
You or your employer has purchased a specific benefit plan from hundreds of combinations available. Some plans base
the amount of benefits on a chart or a schedule of fees arbitrarily developed by insurance carriers. For this
reason, you may feel that a lower percentage of the reimbursement level indicated in your dental plan is received.
For example, if your plan states that it will pay 80% of the cost of dental treatment, it means 80% of the fee
arbitrarily determined by the insurance carrier and not the actual fee charged by our office.
The treatment you need and receive is based on our professional judgement and not on your coverage by a dental
benefit plan. We do not believe it is in your best interest for the doctors to compromise their recommended
treatment to accommodate an insurance program’s maximum benefits that may be considerably less than optimal. We are
more than happy to discuss a treatment plan’s advantages and disadvantages with you thereby involving you, rather
than your insurance company, in the decision-making process.
As a courtesy to you, we will submit your claim to your insurance carrier for payment. Please understand that this
will not guarantee payment from your carrier.
Please remember that the financial obligation for dental treatment is between you and this office. The insurance
company is responsible to you and not to this office. We cannot be responsible for limitations on payments from your
insurance company.
Acknowledgement
You acknowledge, by signing below, our Financial Agreement and Cancellation Policy, and Terms, and Conditions. You
agree to cover all fees, including attorney fees, necessary to collect all debts owed by you to Austin Dental of
Roswell.
