FINANCIAL OPTIONS	
3009 S Mt Vernon (Lincoln Heights), Spokane, WA 99223 | ph: 509.534.2666, fax: 509.534.1392

Our goal is to make quality dental care affordable for our patients.
Service pledge                          	
Our patients receive a written treatment plan, understand their options, know the costs involved and make their own informed choices. We provide accurate diagnosis, objective treatment information, costs estimates, and our best professional option.
Methods of payment                          	
•	Payment is due at the time of service by check, cash, or MasterCard, Visa, Discover.
•	Third-party payment plans are available with credit approval (such as Care Credit).
•	Dental insurance acceptance with patient portion (deductible and estimated co-payment) due at the time of service. 

Dental insurance information                      	
To help our patients receive their maximum insurance benefits we:
•	File insurance claims for our patients and help interpret their benefits and coverage
•	Ensure accurate treatment coding and provide complete information to insurance company
•	Make sure you have the necessary documentation for your records
•	Answer your questions and help you communicate with your insurance company

Please help us assist you in obtaining the maximum benefits specified in your contract:
•	Please have all insurance cards and photo ID available for photocopying at all times. Any changes of insurance, address, phone number or emergency contact should be reported immediately.
•	Please bring a copy of your insurance benefit booklet or login info if you like our help understanding your coverage.
•	Please bring complete policy information (policy no., name and address of insurance company) if you would like us to file your claim for you.
•	Remember, not all services are a covered benefit in all contracts, even from the same insurance company. Some insurance companies arbitrarily select certain services that they will not cover. Individual contract benefits are chosen by your employer. 
•	Keep in mind that dental insurance is a contract between the patient, his or her employer, and the insurance company. Patients are responsible for the full amount of charges for services provided. 
•	Remember that insurance authorizations for services do NOT guarantee payment. If your insurance does not pay in full within 60 days, we ask that you contact them, as charges will then be transferred to you. 

Related information	
•	Balance older than 60 days may be subject to interest charges of 1.7 percent per month, which is an annual rate of 20 percent. Interest fees will be added to the unpaid balance at the end of the month. 
•	There will be a $40.00 fee for all returned check items. 
•	In the rare event than an account is not paid, the patient is responsible for all fees incurred in the collection of the account, including collection agency fees, attorney fees, court costs. 

Signature	
I have read and understand the above information. I understand I am responsible, (regardless of my insurance) for any charges incurred from services rendered. I authorized payment directly to Dr. Hone of the group insurance benefits otherwise payable to me. 
Name of Patient (please print) ___________________________________________________
Responsible party, if other than patient (please print) ___________________________________
Signature_______________________________________________Date_______________