Dr. Matthew Kormylo Patient Treatment and Financial Policy
Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment.
General Thank you for choosing us as your dental care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment.
Missed Appointment(s) and Cancellations: Our goal is to provide treatment promptly with as few visits as necessary. To provide the best services to our patients, we require at least a 24-hour notice for cancellations or rescheduling your appointments.
We understand that unforeseen circumstances may arise, resulting in canceling or missing your appointment. A charge may be charged for multiple missed short notice or canceled appointments.
Multiple failed appointments may result in being dismissed from the dental practice.
Insurance: Please remember your insurance policy is a contract between you and your insurance company. We are
not a party to that contract. As a courtesy to you, we will help you process all of your dental insurance
claims. Please be aware some or perhaps all of the services provided may or may not be covered by your
insurance policy. All charges you incur are your responsibility, regardless of your insurance coverage. As
your dental care provider, we must emphasize that our relationship is with you, our patient, not with
your insurance company.
Payment: Full payment is due at the time of service. If insurance benefits apply, estimated patient co-payments
and deductibles are due at the time of service unless other arrangements are made. Insurance payments
not paid after 60 days will become your complete responsibility and must be paid in full.
Unpaid balances over 30 days old will be subject to monthly interest of 1.5% (APR 18%). If payment is
delinquent, the patient will be responsible for collection payment, attorneys’ fees, and court costs
associated with the recovery of the monies due on the account.
I have read, understand, and agree to the terms and conditions of this Financial Agreement.
