John Coolican DMD, FAGD | Patient Payment Options in Scranton

John Coolican D.M.D., F.A.D.G.                                                                             The Most experienced Mini Implant Surgeon in NEPA

803 S. Main Ave.
Scranton, PA 18504

Integrated Restorative Dentistry              EMERGENCIES

                                                                                WELCOME

 

 

570.906.8281

Patient Payment Options
 

 

                                                                                      FINANCIAL AGREEMENT 

Most of our patients prefer to maximize their  initial payment in order to minimize any monthly payments. Let us know what you had in mind!!

 

IF YOU HAVE INSURANCE :

 

  1. If a Deductible or Copayment applies, You can choose to pay it by ________cash, _________check, _________ credit card (VISA, MASTERCARD, DISCOVER, AMERICAN EXPRESS) on the day that treatment is rendered

      2. Financing is available through our office only with approved credit prior to any treatment through  CareCredit.com. *Interest free for up to 12 months only applies to charges in excess of $ 1000. Please apply for  “CareCredit.com” at http://www.carecredit.com

      3. On extensive treatment, you may prefer to secure a loan via a bank , credit union, or other third-party financing for the entire amount and make payments to the lending institution.

 ***** For extensive treatment (crowns or bridges, implants or other complex procedures that require multiple visits) a payment of no less than 50% is due at the start of  treatment. I certain cases a greater down payment may be  required. The remaining 50% may be broken down into 2 payments. One for mid treatment one for final payment is due on the anticipated day of completion.

 

IF YOU DO NOT HAVE INSURANCE :

      1. You can choose to pay by CASH, CHECK, CREDIT CARD ( Visa, Mastercard, Discover, & American Express ) in full at the time the service is rendered.

    2. Financing is available through our office only with approved credit prior to any treatment through  CareCredit.com. *Interest free for up to 12 months only applies to charges in excess of $ 1000. Please apply for  “CareCredit.com” at http://www.carecredit.com

      3. On extensive treatment, you may prefer to secure a loan via a bank , credit union, or other third-party financing for the entire amount and make payments to the lending institution.

 

Payments; Only allowable prior to treatment with approval by us in writing. The balance on your statement is due and payable when the statement is issued, and is past due if not paid by the end of the month.

 

Charges to Account: We shall have the right to cancel your privilege to make charges against your account at any time. Future visits would then need to be paid at the ti.me of service.

 

Finance Charge: A financial charge will be imposed on each item of your account which has not been paid within thirty (30) days from the date of your statement. The FINANCE CHARGE will be computed at the rate of one & one half (1.5%) percent per month or an ANNUAL PERCENTAGE RATE of eighteen (18%)  percent .. The minimum Finance Charge is $5.00/month on any balance

 

Credit History: You give us permission to check your credit and employment history experience only in the event we may offer in house financing. A credit/employment check is not guarantee of your acceptance for in- office financing.  We have the option to report your account status to any credit reporting agency such as a credit bureau.

Required  payments: Any copayments required by an insurance company must be paid at the time of  service.Because this is an insurance requirement, we cannot bill you for these.

 Returned  Checks: There.is a fee (currently  $25) for any checks returned  by the  bank.

 Missed appointment fee: Patients who do not show up for scheduled appointment, or cancel with less than 24 hours’ notice will be charged a minimum fee of $50. (Depending on the amount of time reserved and the procedure)This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.

 Past due accounts: If your account becomes past due, we will take necessary steps to collect this debt. lf we have to refer your account to a collection agency, you agree to pay all the collection costs which are incurred (approximately 33% of debt) on top of the debt. If we have to refer collection of the balance to a lawyer, you agree to pay all lawyer's fees which we incur plus all court costs. In case of suit, you agree the venue shall be in Lackawanna County, PA.Waiver of confidentiality: You understand if this account is submitted to an attorney or collection agency, if we have to litigate in court, or if your past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separa­ tion remains responsible for the account. After a divorce or separation, the parent authorizing treatment for

a child will be the parent responsible for those subsequent charges. If the divorce decree requires the other parent to pay all or part of the treatment costs, it is the authorizing parent's responsibility to collect from the other parent.

Transferring of Records: You will need to request in writing, and pay a reasonable copying fee (currently $25) if you want to have copies of your records sent to another doctor or organization. You authorize us to include all relevant information, including your payment history. If you are requesting your records to be transferred from another doctor or organization to us, you authorize us to receive all relevant information, including your payment history.

Workers' Compensation: We require written approval/authorization by your employer and/or workers' com­ pensation carrier prior to your initial visit authorizing John P. Coolican DMD, Inc. to perform dental services on your behalf for injuries suffered in said incident.  If your claim is ultimately denied for any reason, you will be responsible for payment in full.

Personal Injury: If you are being treated as part of a personal injury lawsuit or claim, we require verification from your attorney, in the form of a "Letter of Protection" prior to your initial visit. In addition to this verification, we require that you allow us to bill your health insurance. In the absence of insurance, other financial arrangements may be discussed. Payment of the bill remains the patient's responsibility. We cannot bill your attorney for charges incurred due to a personal injury case.

Co-signature: If this or another Financial Policy is signed by an approved co-signer, the co-signer will be responsible for any unpaid overdue balance not paid by the patient including  all  finance charges.

 

Patients name (print)--------------------------------       Patient' Signature : __________________________________

 

Co-signer  (print)                                           ______     Co-signer signature:                                          _____________

 

 

Date : ____________________

 

 

 

 


 

 

 


   

 

 

 

 

 

 

 

 

 

 

 
 
 
Scranton Dentist | Patient Payment Options. John Coolican is a Scranton Dentist.