In the interest of a good health care practice, it is desirable to establish a credit policy to avoid misunderstandings. Our primary responsibility is to help our patients experience good health and we wish to spend our time and energy toward that end.

A treatment plan and estimate of your portion will be presented before your first restorative visit. We will make a best guess estimate but it will only be an estimate. Your portion is due at the visit. For convenience, your portion can be divided by the anticipated number of visits.

Many insurance plans state the coverage is at 50%, 80% or 100%. This is often based on an insurance company fee schedule rather than our fees. Some insurance companies disallow certain services. Your treatment plan estimate may differ from expectation.

Many families believe that it is the insurance company that owes the doctor for his service. Please keep in mind that the insurance contract is between the insured and the insurance company. As a courtesy to our patients, we submit insurance claims and accept insurance payments. However, the ultimate responsibility for payment remains with the family. In cases of divorced or separated parents, custodial parent will be held responsible for the account.

Patients without insurance are required to pay the charges in full at the time of service. A 10% discount will be applied. A treatment plan estimate can be divided by the anticipated number of visits.

The balance on all accounts is due in full within 60 days regardless of insurance coverage or anticipated payment from other sources. A $5.00 monthly rebill fee will be added to all overdue accounts. Patients with insurance claims that haven't been paid in 30 days should contact their insurance company to determine the reason for payment delay. Delinquent accounts will be referred for collection.

Visa/Master Card and Care Credit cards may be used for payment on your account.

There will be a $25.00 charge on all returned checks.

There may be a charge for missed appointments. Our time must be used as efficiently as possible to keep our expenses at a minimum and our fees within reasonable limits.

The undersigned acknowledges financial responsibility for all charges regardless of insurance coverage. If it becomes necessary to effect collection of any amount owed on this or subsequent visits, the undersigned agrees to pay for all costs and expenses, including reasonable attorney fees. I hereby authorize the doctor to release information necessary to secure payment of benefits. I authorize payments of insurance benefits directly to Hai T. Pham, DMD.