Macon Sapp, D.D.S.
3612 Shannon Rd., Suite 205, Durham, NC 27707
Phone: 919-489-9171
Fax: 919-493-1088
Our Office Policy
This patient financial obligations agreement, is entered by and between each of the undersigned
responsible parties and the dentist.
1. 2. Investment – The responsible party’s investment needed to complete the patient’s necessary
dental treatment is based on an estimate derived from an examination of the patient by the
dentist. Should additional unforeseen problems arise as your treatment progresses, this
estimate may have to be revised. The patient will be consulted before any additional treatment
is undertaken. This estimate will be honored, provided treatment is completed within six (6)
months of the date of the examination.
Financial arrangements – Accepted methods of payment: cash, check, credit card (including
Visa, Master card, Discover and American Express) as well as Care Credit. Care Credit is a third
party financing company that gives you the option of financing your treatment for 6, 12, or 18
months (depending on your financed amount) with 0% interest as long as timely payments are
made. Visit www.carecredit.com for further details or inquire from a member of our
3. administrative staff. There will be a $25.00 handling fee for all returned checks.
Insurance assignments – Dr. Sapp is a non-participating provider. However, we file your
insurance claim for you as a courtesy provided ALL insurance information is available to us.
Claims are submitted promptly after treatment is rendered. Because Dr. Sapp is a non-
participating provider, insurance benefits will be refunded to you in the form of a check through
the mail from your insurer. Therefore, our office policy states payment is required in full at the
time services are rendered. Insurance benefits are based on a ”UCR”, or usual and customary
rate (fee), which is set by the insurance company. These fees will not correspond with our fees.
Remember, we are not in network and will be filing as a courtesy.
It is the responsibility of the subscriber/patient to know what his/her eligibility and coverage is
with their current insurance plan. If this is unknown, the patient should verify coverage
limitations prior to services being rendered. We encourage all patients to call their plan
administrator with any questions or concerns relating to specific benefits. Your insurance policy
is a contract between you and your insurance company. We cannot guarantee payment of
claims. We will assist you in working with your insurance company, but ultimately the
responsibility lies within you. Pre-determination of insurance benefits: Prior to proceeding with
extensive treatment (crowns, bridges, dentures, implant restorations) a pre-determination may
be beneficial in order to educate you on your estimated out of pocket portion. Keep in mind that
you may possibly have a deductible and an annual maximum that you are working with in. A
pre-determination can take 2-6 weeks to process and receive from your insurance company. It’s
always best to request a pre-determination be filed with your insurance company at the time of
diagnosis if treatment is being considered.4. 5. 6. Missed appointment policy – Once an appointment has been made, please remember this time
has been reserved especially for you. In the event circumstances deem the need to reschedule,
please supply us with as much of a notice as possible. There will not be a charge for rescheduled
appointments. However, multiple “missed” appointments (no shows) will be charged a fee of
$50.00 per visit after missing the third visit.
Collection fees - The responsible party shall pay all of the dentist’s reasonable expenses
incurred to enforce or collect any of the obligations under this agreement (including, without
limitation) reasonable arbitration, attorney and experts fees and expenses, whether incurred
without the commencement of a suit, in any trial, arbitration, or administrative proceeding, or
in any appellate or bankruptcy proceedings. Submission to treatment implies consent to
treatment implies consent as outlined in this service agreement.
Financial Consent – The patient (together with the patient’s guardian) and the responsible party
promise to pay for all services to the patient and agree to be fully responsible for the total
payment of procedures performed in the office, including any treatment not benefit of dental
insurance the patient may have. The patient and the responsible party herby grant the dentist
permission to check credit as deemed appropriate by the dentist. Each of the undersigned
patient and responsible party herby agree to continue and remain bound for the payment of the
obligations due under this agreement and all interest fees thereon, not withstanding any
extension of time which may be by the dentist. This agreement is of a continuing nature and
shall apply to services provided by the dentist to the patient on future visits.
I, each of us, certify that I have read, understood and agreed to this agreement. I have
received a copy of this patient financial obligations form.
Consent
I understand and agree to this financial policy.
Patient Signature:
(Parent/Guardian if under 18)
______________________________________________ Date: _______________________