Insurances and Billing Information
Our office accepts many dental insurances. As courtesy to our patients, we currently will bill your insurance company on your behalf. We are happy to assist you with any questions about your coverage or whether your insurance is one accepted by our office. You can call your carrier or us! It is the patient’s responsibility to keep the office informed of all current information and cannot take responsibility for your omissions.
For your convenience, we accept the following methods of payment: cash, checks, major credit cards (Visa, Mastercard, Discover, American Express), Health Savings Account and Care Credit (ask for details).
A $35 fee will be assessed for any returned checks. Subject to change.
If your balance is not paid in full within 60 days of the billing date, a late charge of 1.5% on the unpaid and owed balance will be assessed monthly. Please realize that failure to keep this account current may result in being unable to receive additional dental services except for dental emergencies, or where there is prepayment for additional services. In the case of default on payment of this account, the patient agrees to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances.
Authorization, Release and Agreement to Pay for Services
By becoming a patient of record, you authorize Dr. Louie and staff to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of your dental needs. You consent to media useage where your teeth and or likeness may be used in the office website. We will not use your name and ask for permission before posting your likeness and you may also decline this portion only. You authorize and consent for Dr. Louie and staff to perform any and all forms of treatment, medications and therapy, that may be indicated in connection with the patient and further authorize and consent to treatment by the doctors who will choose and employ such assistance as they deem fit. You also understand that the use of anesthetic agents embodies a certain risk and consent to its use. No treatment will commence without your consent.
Patient will authorize Doctor to release any information including the diagnosis and the records of any treatment or examination rendered to you during the period of such dental care to third party payors and/or other health practitioners. I authorize and hereby request my insurance company to pay directly to the Dr. Louie otherwise payable to you. It is understood that it is your responsibility for payment of dental services provided in this office for yourself or your dependents in full, it is due and payable at the time services are rendered unless financial arrangements have been made, regardless of insurance coverage.