Eastgate Family Dental
Grand Rapids, Michigan
2003 Burton St SE · Grand Rapids, MI 49506
Phone: (616) 245-9830 · Fax: (616) 245-5026
www.eastgatefamilydental.com
Financial Policy

Thank you for choosing Eastgate Family Dental as your dental care provider. We are committed to providing you with the highest quality care. Please take a moment to read our financial policy carefully. All patients must complete our information and insurance forms before seeing the doctor.

Payment is due at the time of service unless prior arrangements have been made. We accept the following forms of payment:
Cash Personal Check Visa Mastercard Discover HSA Cards FSA Cards
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Regarding Insurance

Your dental insurance is just that: your insurance. We are familiar with most dental plans and are happy to assist you in understanding your benefits. Please be aware that a majority of dental plans require a co-payment and/or a yearly deductible from the patient. This co-payment is due when services are rendered.

We will gladly submit dental claims to your insurance company on your behalf. While we make every effort to maximize your insurance benefits, any uncovered dental charges remain the responsibility of the patient. Our relationship is with you, not your insurance company.

We are familiar with most dental plans so please don't hesitate to ask our front desk staff if you have questions about your coverage before your appointment.

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Eastgate Membership Plan

Unlike dental insurance, our in-house membership plan is a direct arrangement between you and Eastgate Family Dental, with no insurance company, no claim forms, no waiting periods, and no annual maximums. If you do not have dental insurance, our membership plan may be an excellent alternative.

Members receive preventive care and significant discounts on most other services, all for a simple annual fee paid directly to our office. No middle man. Ask our front desk team for details. We'd love to tell you more.

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Usual and Customary Rates

Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's determination of usual and customary rates.

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Adult Patients

Adult patients are responsible for full payment at the time of service, unless prior arrangements have been made.

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Minor Patients

The adult accompanying a minor and/or the parents or guardians of the minor are responsible for full payment at the time of service. For unaccompanied minors, non-emergency treatment will be provided only if charges have been pre-authorized to an approved payment method, or if payment is made by cash or check at the time of service, unless prior arrangements have been made.

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Missed Appointments

We understand that life happens. If you are unable to keep your appointment or need to make a change, we ask that you give us reasonable notice by calling us at least 48 hours in advance. We try as a courtesy to call a day or two before your appointment as a reminder.

Ultimately, it is your responsibility to keep your reserved appointment time. A fee may be charged for appointments cancelled without reasonable notice. Multiple missed appointments may affect your ability to schedule future appointments.

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Financial Considerations

We require payment for services on the day they are performed unless prior arrangements have been made. This policy enables us to minimize our bookkeeping costs and helps us keep our fees as fair and as low as possible.

For extensive services such as crowns, bridges, and dentures, you are entitled to a detailed treatment plan and cost estimate before treatment begins. We are happy to discuss payment arrangements for larger cases. please speak with our front desk team.

Thank you for understanding our financial policy. Please let us know if you have any questions or concerns. We are here to help.


Patient Acknowledgment

I have read and understand the Financial Policy of Eastgate Family Dental. I agree to abide by its terms and understand that I am responsible for all charges incurred for dental services provided to me or my dependents.

Signature of Patient or Responsible Party
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Signature of Co-Responsible Party (if applicable)
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