Payment/Cancellation Policy
Payment at the time of services is expected. For your convenience, we take Care Credit, Credit or Debit cards. Our office will be happy to submit claims to your insurance company. A service charge of 1-1/2% per month will be added to all balances 60 days and older. The annual rate of the service charges is 18%. I understand that GoClinicTurkey Dental will make every effort to collect from my insurance company. I hereby authorize GoClinicTurkey Dental to furnish information to insurance carriers concerning my treatment and I hereby assign to the dentist all payments for dental services rendered covered by insurance for services rendered to me or my dependents. I also acknowledge and understand that if the account is turned over to an attorney for collection, I hereby agree to pay thirty percent (30%) attorney or collection agency fees on the unpaid balance.
Please understand that our appointment times are scheduled to allow us to take care of each individual patient’s needs during the patient’s visit. Since appointment times at GoClinicTurkey Dental are in high demand, we value advance notice from our patients who are unable to keep their scheduled appointments.
In an effort to decrease unnecessary costs related to staffing and supplies and in order to contain our costs and continue to provide you with affordable fine dentistry for your entire family, we maintain a No-Show/Cancellation Policy for all of our patients. To promote efficient access to our clinic, we require that any appointment that is no longer needed or is unable to be kept, must be cancelled at least 72 hours in advance of the appointment. Cancellations must be made during normal business hours on workdays at least tree full business day before the scheduled appointment. Cancellations must be done over the phone by speaking directly to one of our dental professionals. Patients will not be charged if cancellation is made 72 business hours before their appointment.
Since we certainly understand that illness or other problems can occur (sometimes without any warning), we will not charge you for your first missed or cancelled appointment. In the event a second appointment is missed or cancelled with less than 72 hours notice, or no notice, a £200 charge will be billed. If a third no-show or same day cancellation occurs, we reserve the right to terminate the doctor-patient relationship as well as another £400 charge.
This policy is in effect for all appointments at our office. Please acknowledge that you have had the opportunity to review this policy by signing below.
The undersigned hereby authorizes the release or any information relating to all claims for benefits submitted on behalf of myself, spouse, or dependents including the assignment of benefits payable to GoClinicTurkey DENTAL, I further agree and acknowledge that my signature on this document authorizes my dentist to submit for myself, spouse, or dependents all insurance claim forms necessary for submission and that I will be bound by this signature as though the undersigned had personally signed the particular claim form.
Past due balances are subject to a late payment of 1-1/2% per month (18% annual).
