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Sample Forms & Policies
Please note that these have not been evaluated by an attorney, nor are they intended to provide you with legal advice. We advise that any forms you provide for patients to sign be evaluated by your Risk Management team or attorney.

Medical Insurance & Dental Benefit Plans

If you have insurance we will help you determine the coverage you have available. In order to best assist you, it is important that you submit your dental and/or medical insurance information to us with your New Patient Paperwork a minimum of two business days prior to your scheduled appointment. This allows us time to contact your insurance company and obtain a breakdown of the benefits your employer or you have purchased from the company. In addition, you will want to bring a dental benefit book that your carrier should be able to provide. Our business team will be happy to help you understand your policy.

Should you be diagnosed with treatment services, we will be able to provide you with a detailed plan which will give you an estimate of how much your insurance company may pay for each procedure, as well as the portion you will be expected to pay at the time of service.

Professional care is provided to you, our patient family, and not to an insurance company. The insurance company is responsible only to the patient as a benefit from the employer or individual plan purchase, and the patient is responsible to the doctor. We will assist you in every way we can in the filing of your dental or medical claim and handling of insurance questions from our office on your behalf.

Financial Policies

In an effort to reduce the cost to you, the patient, while maintaining the highest level of professional care, we have established the financial policy as follows:

•  Payment of any account balance is due in full within 20 days of statement date.
•  We gladly accept Visa, Discover, American Express, or MasterCard payments.
•  Payment plans are available through...

We bill your dental plan as a courtesy to you, our patient, and will provide you with an estimated treatment plan prior to your dental services. This treatment plan will outline your expected patient portion based upon the information your insurance plan has provided to us regarding your dental benefits and the treatment diagnosed. Your patient portion is due at the time of service, in full. Any amounts still owed after your insurance claim has been paid will be submitted to you via billing statement, and will be due within 20 days of that statement date.

Any billed amounts that are past due 90 days will be submitted to an outside agency, and you may be responsible for additional fees as outlined below.

Office Fees

Our office fees are outlined below. By signing this financial agreement, you agree to all application of fees as defined below.

Broken Appointment Fee - $50
Collections Transfer Fee - $25
NSF Fee - $25 (per Oregon law - check with your state for maximums)

Sample Policy Downloadable

ReCare & ReActivation

ReCare Scripting
ReActivation Sample Letter


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Opportunity | | 503-719-4869
4420 NE 86th Avenue, Portland OR 97220



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