FinPolicy

FINANCIAL POLICY

FOR PATIENT: _____________________________________________________

THIS FINANCIAL POLICY is in effect for orthodontic treatment that will take up to 24 months of active treatment or for the designated time in your written orthodontic treatment estimate. At the end of active orthodontic therapy there will be a RETENTION PHASE of treatment that will, in most cases, be a lifetime commitment. Everyone’s teeth have tendency to slowly relapse or return to or towards their original tooth positions. Long term RETENTION of the finished result is the patient’s responsibility. Our office will provide periodic retainer checkup / adjustment appointments usually once or twice a year. The current fee for retention appointments is $45.00 per visit. There also will be additional fees charged in the retention phase for periodic x-rays to check wisdom teeth, unerupted teeth, growth and development. You will always be informed prior to our office providing additional services after active orthodontic treatment and quoted the charges for that service. If you have recent x-rays from another healthcare provider, please bring them to your retention appointments.

MONTHLY PAYMENTS must be received on or before the 10th day of each month to avoid the $15/month billing fee. We do not regularly send monthly statements to our patients. For your convenience, we will provide mail-in payment coupons. Our office accepts personal checks, credit/debit cards, online payments and cash paid at your appointments. If you pay cash, ALWAYS ask for a receipt. In the event of an unapplied credit to your account, we can not give you credit without your canceled checks, bankcard receipts or receipts for cash payments.

Payment at your scheduled visits is acceptable, if before the 10th of each month. Our computer system automatically generates late charges if you do not have your payment posted on or before the 10th of each month. We also accept bankcard payments by phone. All monthly payments should be made payable to either Affordablebraces.com or Paul L. Ouellette, DDS, MS and mailed to one of the following addresses:

FLORIDA PRACTICES	GEORGIA PRACTICES
AffordableBRACES	AffordableBRACES
River's Edge Professional Center	3530 Mall Blvd.
455 Magnolia Avenue, Suite B	Suite B
Merritt Island, Florida 32952	Duluth, Georgia 30096
To Call In Credit Card Pmts 321.453.7750	To Call In Credit Card Pmts 770.622.9291

FREQUENCY of office visits has no relation to your case fee or your monthly payment. In the beginning of orthodontic treatments you will be seen more frequently (2-4 week intervals). During your active care you may require less frequent office visits (6-8 week intervals). Each payment plan is personally customized to meet your financial obligation with our office. SKIPPED OR LATE monthly payments are subject to a $15/month billing fee.

EXTENDED TREATMENT beyond the maximum treatment time designated in your written treatment estimate is subject to additional fees. Most cases finish in the prescribed time. However, extended treatment time due to poor cooperation, growth problems, traumatic injury or other unforeseen complications will be charged up to $150/month until the case is completed.

IF SERVICES ARE TERMINATED for any reason before the completion of treatment, the account will be adjusted and a just settlement determined, based on the amount of treatment completed.

SERVICES PROVIDED BY OTHERS such as routine general dentistry, oral surgery, implant dentistry, laboratory services and other outside healthcare services are not part of your orthodontic treatment.

EXCESSIVE BREAKAGE OF ORTHODONTIC APPLIANCES or loss of removable appliances, retainers are not included in the contract fee. There will be fees for repairs or replacements to be determined at the time of the incident.

IF ORTHODONTIC INSURANCE covers all or part of the case fee, it may be paid directly to our practice or to the policyholder as agreed to by each party. The FINANCIALLY RESPONSIBLE PARTY must pay whatever part of the account balance not paid directly to the practice by the insurance company.

DISCOUNT INSURANCE PLANS in most cases provide a 15% to 25% discount off our published fee schedule. As a rule our office charges a “flat” or “bundled” fee that includes one or more of the orthodontic services listed on our fee schedule. When quoting a discounted fee our office computes the fee on “unbundled” or full fee for service basis with no professional discounts. For example, a child case may require the following services from our published fee schedule (See Sections A –E): A: Initial Diagnostic Records Inclusive @ $300; D: Comprehensive Treatment of Adolescent Dentition @ $4,500; E: Appliance(s) Removal, Construct & Place Retainer(s) @ $850. The total fee before discounts would be $5,650. A 25% fee reduction would make your final cost $4,237.50. All other discounts or coupons would not apply to this type of insurance plan.

I have carefully read, understand and agree to the office financial policies described above:

Patient / Parent Signature(s) X_____________________ X_____________________ Date Signed ________

PLEASE PRINT FORM AND BRING TO YOUR NEXT APPT. THANK YOU....Dr. Paul Ouellette & Staff

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