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20171 Icenic Trail
Lakeville, MN 55044
Practice Logo Large
20171 Icenic Trail
Lakeville, MN 55044

Financial Agreement

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Thank you for choosing Lakeville Dental as your dental healthcare provider. We are committed to providing you with the highest quality comprehensive dental care, so that you may attain optimum oral health. The following is a statement of our financial policy, which we require that you read, agree to, and sign prior to any treatment.

Payment Policy: Payment is due at the time service is provided. Our office accepts cash, personal checks, credit cards, and patient financing available through CareCredit.

Dental Benefits:
  • We must emphasize that as your dental healthcare provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and your insurance company.
  • If you have provided us with your dental insurance information, we will file your claim as a complimentary service for you.
  • We are happy to provide you with an estimate of what we believe your dental benefits will cover based on the information provided to us from your insurance company. Please know that this is not a guarantee of what will be covered by your insurance company. Your insurance company and plan benefits will ultimately determine the amount paid.
  • Your deductible and co-payment, which is the estimated amount, not covered by your insurance company, are due on the day of service.
  • We are happy to accept Assignment of Benefits whenever your benefit plan allows. Assignment of benefits is plan specific and between you, your employer, and your insurance company. If your plan does not allow assignment of benefits, you are responsible for payment in full at the time of service is provided. We will file the claim as a courtesy, and your insurance company will reimburse you directly based on your dental benefits plan.
  • We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. However, if your insurance company has not made payment within 60 days, you will be responsible for paying the full amount at that time. Our office will not enter into a dispute with your insurance company over any claim.
  • We are happy to help you review your dental benefits and answer any questions you may have; however, you are responsible for understanding your dental benefits.
  • You have ultimate financial responsibility for your account regardless of whether your insurance covers your treatment.

Past Due Accounts: A finance charge of 0.5% per month (6% annual percentage rate) will be calculated and added to the outstanding balance on accounts that are 30 or more days past due. If necessary, unpaid accounts will be transferred to a collection agency.

We thank you for the opportunity to serve your dental health care needs and welcome any question you may have concerning your care or our financial policy.

Contact our office today to schedule your appointment!

20171 Icenic Trail Lakeville, MN 55044
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