We are glad to assist you in the filing of your dental insurance as a courtesy to you as our patient; therefore, all dental benefits are assigned to Dr. Wayne T. Fieldsmith, DDS, INC. Our fees are established to allow our staff to provide quality dental care and we pledge the same quality of care to all our patients. Please be aware that you are responsible for any and all fees, regardless of your insurance coverage. If payment is not received from your insurance company for any reason, you will be notified and payment will be due immediately. Your insurance company may require a deductible and or copayment at the time of service. Please be prepared to pay these fees at your appointment time.
Payment for emergency and first appointments must be paid the day of treatment. In order to keep our fees as low as possible, we do not offer payment plans, but we do accept all major credits cards, cash, as well as personal checks. We also can request a payment plan through Care Credit® as a means of outside financing.
Request for Credit on Outstanding Balance
If you require us to file on your insurance, you must sign a request for credit for any outstanding balance on your account. I hereby apply for credit from Dr. Wayne T. Fieldsmith. I authorize you to contact creditors, past and present, obtain reports from credit bureaus, and make any other inquiries as deemed necessary in connection with the collection of this account. I understand that I may be charged a finance charge if my balance goes beyond 90 days. I agree to abide by these terms of payment and understand the responsibility for my account.