4420 Conlin Street, Suite 204, Metairie, LA 70006 | Phone (504) 456-0964

Financial and Insurance Polices

Thank you for choosing our office for your dental needs. Dental treatment is an excellent investment in an individual’s medical and psychological well-being.  Financial considerations should not be an obstacle to obtaining this important, life-enhancing care.  We are always available to answer your questions and/or assist you in any way we can.

As a courtesy to you and your family, our office will send claims, letters, x-rays and any other necessary information to your insurance company for reimbursement of your dental treatment.  You, however, are responsible for monitoring your benefits and for remaining within you maximum covered benefit during each year of coverage. Please know that we will do everything possible to see that you receive the full benefits of your policy.  The deductible and estimated percentage your insurance company does not cover is to be paid in full upon the date of service.  After 45 days, any remaining balance from unpaid insurance claims will be your personal obligation.  We would like to keep a credit card on file in the event your account is past 45 days.  We will always call you prior to any payment made on your card. 

Fees generated by the providers are not governed by the provisions of the patient’s insurance policy.  Our office is not responsible for collecting your insurance payment or negotiating settlements on disputed claims.

I understand that I am ultimately responsible for payment of dental services provided by this office for me or for my dependents is mine.  Payment is due at the time of service; however, in some instance we may agree to provide additional time and/or terms of payment.  No refunds for professional services rendered will be given.  Estimates can be provided for the amount of service required, however estimates on percentages covered by insurance carriers are not guaranteed.  I understand that any insurance estimate given to me by this office is not a guarantee of actual insurance payment. For a more accurate estimate of insurance benefits, a written pretreatment estimate for your carrier would be needed.  We reserve the right to add billing charges or interest at the rate of 1% per month to unpaid accounts.  A credit report may be used in connection with your account prior to or after providing services.  In the event of default, I (we) promise to pay any legal interest on the indebtedness, together with such collection costs, certified letters and reasonable attorney fees as may be required to effect collection of this note. 

It is important to make the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.  We accept all major credit cards, cash and checks.  There is a $25.00 per check NSF fee, if a check is returned with non-sufficient funds available. 

Assignment of Insurance Benefits:

I authorize that payment of benefits be made directly to Dr. Joseph P. Simone II, LLC.  I further authorize the dentist to obtain payment from my insurance carrier.

Treatment Consent:
I consent to treatment by Dr. Joseph P. Simone II and/or staff.