Office Policy & Financial Agreement

For the convenience of our patients, the following office policy and financial agreement has been established. In fairness to all, no exceptions are permissible.

Financial Options

Accepted payment methods are: Check, Cash, Visa, Master Card, Discover and American Express. We also have a 6 and 12 month interest free payment program through Care Credit, a healthcare financing company. If you require longer than 12 months, Care Credit offers low interest payment options up to 60 months. We cannot extend payments in our practice over 90 days.

Account Balances over 90 Days

Statements reflecting a balance of $ 3.00 or more will be sent each month, balance is due upon receipt. Finance charges will be applied to accounts that are aged 90 days after the date of service. Accounts over 120 days will be submitted to a collection provider if no previous financial arrangements have been made. If the account is turned over for advanced collection services, the patient or responsible party will be expected to pay all collection fees, court costs, and reasonable attorney fees.

Delta Dental Patients

Please note effective 1-1-2020, Delta Dental will be issuing the payment to the patient vs. to our office. **You may endorse the Delta Dental check and forward to our office OR you may pay at the time of you appointment, then keep the insurance check for your reimbursement.** Please do not overlook any correspondence from Delta Dental as payment may be enclosed.

Cancellations

As a courtesy to all patients we ask that a 2 business days notice be given for a cancelled appointment. If we have not received sufficient notice, a charge will be applied to your account.

Release of Information

The undersigned has read the above and agrees, whether he/she signs as responsible party or as patient, to pay the account of Kurt D VanWinkle, DDS, MSD, PC in full without regard to insurance coverage. The undersigned further agrees to assign any/all insurance benefits be paid directly to Kurt D VanWinkle, DDS, MSD, PC and agrees to release any information requested by the insurance carrier.

In the case you are running late, please give our office a call 317-844-2792. If you are more than 15 minutes late to an appointment, we will have to reschedule your appointment.