Patient Information
For your convenience, we accept cash, personal checks, money orders, and most major credit cards. Payment is expected at the time services are performed. Feel free to contact our office if your treatment plan requires more comprehensive dental work and you want to discuss financial arrangements.
Dental Insurance
Insurance Policy Downtown Phoenix Dental
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services regardless of contracts between yourself, your employer and your dental insurance company. This office will submit the patient’s insurance forms or assist in making collections from insurance companies. We will credit any such collections to the patient's account. This dental office is a provider of professional services only, and cannot provide treatment on the assumption that a specific procedure is a covered expense by your dental insurance carrier. Each patient is ultimately responsible for understanding their dental insurance policy limitations and content.
A re-billing fee may be assessed on the unpaid balance on accounts exceeding 45 days. Patients will be billed for unpaid insurance claims exceeding 30 days. A missed appointment fee may be assessed on patient appointments not cancelled within 24 hours of the scheduled appointment time. The patient will be responsible for any fees or services charges imposed by collection agencies. I understand that the fee estimate listed for this dental care can only be extended for a period of sixty days from the date of the patient examination. If the patient’s insurance coverage changes, any treatment arrangements may be invalid. In consideration for the professional services rendered for me, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
Financing Options
CareCredit is here to help you pay for treatments and procedures your insurance does not cover. They offer No Interest* financing or low minimum monthly payment options so you can get what you want, when you want it.
With three simple steps, including an instant approval process, it's easy to apply for Care Credit. After you're approved, you're free to use CareCredit to finance our services.
Now you don't have to worry about saving up for the procedures you want and need. With CareCredit, the decision's in your hands to get what you want, when you want it. For more information or to apply online, visit carecredit.com
Financial Policies and Consent for Dental Services in the Office of Ben Berschler DMD , LLC
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred for their care. Financial responsibility on the part of each patient must be determined before treatment. If we can not verify your insurance coverage prior to treatment, payments in full for professional services are due upon demand. All dental services performed without previous financial arrangements, must be paid for in cash, check, credit card, CareCredit , at the time services are rendered.
Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services regardless of contracts between yourself, your employer and your dental insurance company. This office will submit the patient’s insurance forms or assist in making collections from insurance companies. We will credit any such collections to the patient's account. This dental office is a provider of professional services only, and can not provide treatment on the assumption that a specific procedure is a covered expense by your dental insurance carrier. Each patient is ultimately responsible for understanding their dental insurance policy limitations and content.
A re-billing fee may be assessed on the unpaid balance on accounts exceeding 45 days. Patients will be billed for unpaid insurance claims exceeding 30 days. A missed appointment fee may be assessed on patient appointments not cancelled within 24 hours of the scheduled appointment time. The patient will be responsible for any fees or services charges imposed by collection agencies. I understand that the fee estimate listed for this dental care can only be extended for a period of sixty days from the date of the patient examination. If the patient’s insurance coverage changes, any treatment arrangements may be invalid. In consideration for the professional services rendered for me, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. This practice is in compliance with HIPAA Act, 1996.My provided information will be used for administrative, dental treatment or insurance purposes only. Notice of HIPAA privacy practices can be accessed via our web-site www.DTPHXdental.com , under “HIPAA”. My signature below acknowledges my presentation of this office’s HIPAA privacy policies. I have read the above conditions of treatment and payment and agree to their content.