Dr. Scott Byrd
Our commitment is to provide quality dental care to the entire family through exceptional service and the utilization of advanced technology.
PAYMENT IS EXPECTED AT THE TIME THAT SERVICE IS RENDERED METHODS OF PAYMENT:
1. Cash, Check, Money Order, or Credit Card
2. Dental Insurance (see guidelines below)
3. Care Credit
DENTAL INSURANCE GUIDELINES:
1. We are pleased that you have dental insurance, and our office will assist you in obtaining the maximum benefits specified by your contract. However, your insurance contract is between you, your employer, and the insurance company.
2. As a courtesy to you, we will file your insurance, however, we require that your estimated co-payment and deductible be paid at the time of service.
3. Not all services are a covered benefit in all contracts. Some insurance companies select certain services they will not cover. Any service not covered is your full responsibility.
MCNA & DELTA DENTAL SMILES PATIENTS:
Please be aware that with current OHS rules, a Delta Dental Smiles or MCNA member is responsible for charges for non-covered services, including services received in excess of Medicaid benefit limitations.
By signing this form you agree that you accept responsibility for any and all charges that occur that Medicaid does not cover.
1. Returned checks and balance older than 30 days may be subject to additional collection fees. These fees will be added at the end of each month.
2. In the event that the account is not paid and we refer the account to collection, you will be responsible for all fees incurred for the collection of your bill. (i.e., attorney fees, court costs, and collection agency fees)
3. Due to the rising cost of lab fees, all procedures that require lab involvement will require payment in full by the time we complete your case.
4. Your appointment time has been reserved exclusively for you. Any change in your appointment affects many patients. Please give us 48 hour notice of any changes in your appointment. Failure to do so will result in a $5O fee.
I understand if I have an unpaid balance to Dr. Scott Byrd, DDS and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of any fees from the collection agency, including all costs and expenses incurred collecting my account, and possibly including reasonable attorney's fees if so incurred during collection efforts.
In order for Dr. Scott Byrd, DDS or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that Dr. Scott Byrd, DDS and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using prerecorded/ artificial voice message and/or use of an automatic dialing device, as applicable.
I have read and understand the above information. I understand that I am responsible (regardless of my insurance) for any charges incurred from services rendered.