443-207-8455 Fax: 443-485-6584support@alphadentalelkton.com

ALPHA DENTAL CENTER
300 E. PULASKI HWY
ELKTON, MD 21921
443-207-8455

To Our Patients:

Welcome to Alpha Dental Center . We are pleased that you have chosen this office for your dental needs. We
would like to take this time to explain our payments policies. If you have any questions please feel free to ask.

1.    We require PAYMENT at the time of services are rendered. You may request an ESTIMATE of the charges for any procedure. If you are unable to pay in full please let us know BEFORE any dental work is done.

2.    We accept Visa, MasterCard, American Express, Discover, Care Credit and cash as methods of payment. We do not accept personal checks.

3.    We accept most private insurance plans and will gladly file your insurance claim for you. However if the insurance DOES NOT PAY the provider directly, YOU WILL BE ASKED TO PAY THE BILL AT THE TIME SERVICES are rendered. If we accept your insurance benefits you will be responsible for your portion at the time services are rendered. If you are UNABLE to do so, please let us know BEFORE we perform any procedures. Insurance coverage is only an ESTIMATION of benefits. GUARANTOR IS RESPONSIBLE FOR ALL TREATMENT NOT COVERED BY INSURANCE.

4.    We ONLY submit claims to PRIMARY insurance plans. Unfortunately, our office does not submit claims to SECONDARY or THIRD insurance parties. It is the PATIENT’S responsibility to pay secondary or third insurance payments. YOU may submit to those companies to receive reimbursements, if any.

5.     If you are employed by the FEDERAL government you may have MORE than ONE insurance plan. If Blue Cross Blue Shield is your medical plan PLEASE inform our office so we can verify your PRIMARY dental coverage.

6.    Appointments cancelled or broken without 24 hours advanced notice will be charged a fee of
$25.00 per half an hour.

7.     Copies of records have an additional charge of $25.00 per patient.

8.    I, further agree in the event of a non-payment of any bad debt owed to Alpha Dental Center , to bear the cost of collection, and or Court cost and reasonable legal fees should this be required.

9.    I, fully understand that Family Dentistry is an AMALGAM free office. We perform Composite Restorations (Ex. Tooth coloring fillings). Please refer to your dental network policy for further explanation on coverage, any Group Dental member’s need to refer to their coverage booklet. Group Dental has made changes to your coverage plan.

10.          I, understand that Alpha Dental Center is NOT RESPONSIBLE for explaining my dental policy, and I’m aware that I will have a CO-PAYMENT for the difference between Amalgams vs. Resin-Composite fillings.

*NOTE: IF THE PATIENT IS UNDER THE AGE OF 18, THE PARENT/GUARANTOR MUST SIGN THE PAYMENT POLICY.*

I understand the financial policies of this office and explained above and agree to abide by them.