Financial Authorization
Root Canal Specialty Associates complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Root Canal Specialty Associates does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Patients With Dental Benefits
We will contact your dental benefit company and will be given a summary of your group benefits. Your benefit company has not guaranteed that any treatment in our office will be a covered expense.
- Your estimated portion will be calculated based upon the referral information provided to us when your appointment was scheduled, and group summary information that we obtained from your dental benefit company. Therefore, any additional and/or unanticipated procedures or services will increase your estimate. All estimates are subject to change.
- We do not guarantee that the estimated portion you are asked to pay will entirely satisfy your payment responsibility. Your estimate could be affected by, but not limited to, your benefit plan deductibles, annual maximums, eligibility, fee limitations, frequency, and waiting periods. Although your estimated portion is due today, your dental benefit company dictates that all services are billed upon completion.
- You may receive a statement from our office for any remaining balance that your dental benefit company does not pay. This balance is due in full immediately upon receipt of the statement. If your dental benefit company pays more than we have estimated, we will send you a refund check.
- Your consent to treatment and the above fee is an agreement between our office, Root Canal Specialty Associates and you, the patient. This does not constitute any type of agreement between our office and your dental benefit company. You are ultimately responsible for the entire fee.
- Dental benefit companies are expected to process and pay claims within 45 days. As a result, any balance not paid by your benefit company within 45 days of your treatment date will become your responsibility.
- If you would prefer a written determination (not a guarantee) from your dental benefit company of your individual benefits, we will reschedule your treatment appointment for approximately 4-6 weeks from today. This will allow the necessary time for your benefit company to respond to our request for information.
All Patients
- You are required to pay your full fee or estimated portion at the time of treatment.
- We accept cash, your personal check (local bank only), MasterCard, Visa, Discover, AMEX and CareCredit, Google Pay, and Apple Pay.
- A monthly service charge of 5% will be assessed to a patient’s account balance after 30 days.
- A fee of up to $35.00 will be assessed to an account if your personal check is returned for non-payment and in the event that collection services are necessary.
- Should treatment be necessary, you will be asked to sign this form in our office.
- The full fee or estimated amount is due at the time of treatment.