LIBERTY FAMILY DENTAL

Marta P. Speakman, D.D.S., P.C.
740 Florsheim Dr.
Libertyville, Il 60048

FINANCIAL POLICY

Thank you for choosing our office for your dental needs. We realize that every person’s
financial situation is different. For this reason, we have worked hard to provide a variety
of payment options to help you receive the dental care you need and deserve that allows
you to enjoy a healthy, beautiful smile with respect to your budget. We are
always available to answer your questions or assist you in any way we can.

To maintain the practice operations and to prevent potential misunderstandings, we
ask patients to accept and adhere to financial arrangements regarding their dental
treatment. Payments are expected at the time services are rendered. We accept cash,
checks* and all major credit cards.

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients as well as from their insurance providers for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.


All Emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time of services are performed.


If you have dental insurance you are responsible for all fees and estimated co-pays and the difference between actual benefit plan payment and the PDP fee for services provided. This payment is expected at the time of service based on the estimate of your dental plan benefits.

If you wish us to file insurance claim for you - Social Security # and copy of your Drivers License will make the procedure much more efficient.
 

Optional Payment Terms:

1. Cash, checks* or Credit Card Payment for Entire Treatment Plan:
• Total treatment plan : $500-$1500 = 5% discount
• Total Treatment Plan: $1500 and over= 10% discount.

2. Pay As You Go for Each Treatment: Total Paid at Time of Treatment
• 5% Discount when paid by Cash or Checks*
• 0% Discount when paid by Credit Card

3. Major Service Payment Option: We offer a two-payment option for Crown, Bridge, and Denture treatment. We ask you to pay ½ of portion at the first appointment and second half at the delivery date appointment.

4. Payment Over Several Months By arrangement with Care Credit, we offer our patients, upon approval, an interest- free term loan (up to 6 months) with no down payment, no annual fee, and no prepayment penalty. Please ask for an application.

DOCTOR PAYS THE INTEREST!

A service charge of 1.5% per month on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied.

Broken appointments: This time that has been reserved especially for you and we
strongly encourage all patients to keep their appointments. If you must change your
appointment, we require at least 24 hours notice to avoid a $70.00 cancellation fee
(emergencies are an exception).

*option for established patients only

I understand that I am financially responsible for any and all dental services rendered to me, regardless of my insurance coverage. The above stated payment options are the only options available of which I have selected one. I also understand and accept all the contents of this financial policy.
Patients Name________________________________________
Responsible Party’s Signature____________________________ Date_______________
 

Dental Benefits

We believe that you deserve the best care. That’s why we always present you with the best dental solution possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental benefits but some don’t. If you have dental benefits, congratulations! You are very fortunate. Here are some important things you should know………

Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits please contact your employer or insurance company directly.
Dental benefits differ greatly from medical benefits. In 1959, most dental benefit plans had a yearly maximum cap of $1,000. You’ll be surprised to know today that the average dental benefit plan has a yearly maximum cap of $1,000. There has been no significant increase in the yearly maximum cap in over 40 years! However, there have been significant increases in your premiums.

Dental benefit plans will never pay for completion of your dental care. It is only meant to assist you.

We currently accept all private care insurance plans (plans that do not require you to select a dentist from a list or require our office to accept a reduced fee for service). This means that we work with literally thousands of companies. Although we can maintain computerized histories of payment by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service.

We estimate your portion based on the most up-to-date information we have, but it is ONLY AN ESTIMATE. If you would like to know your exact insurance benefit, we will be happy to file a “pretreatment authorization” with your insurance company prior to treatment. This does delay treatment but will give you the exact out of pocket figures you may require.