Our goal is to provide you with the best dental care available. A clear understanding of our financial arrangements is essential for a successful doctor/patient relationship.

As a condition of the treatment performed by the providers of Newport Dental Arts; financial arrangements must be made in advance for the full cost of proposed treatment. The practices' vitality depends upon payment for services rendered and it is the responsibility of the patient to satisfy the costs incurred in dental care. Financial arrangements on the part of each individual must be determined prior to treatment completion.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for at the time services are rendered,

Individuals who carry dental insurance understand that all dental services furnished are charged directly to the patient and that said patient is personally responsible for payment of all dental services provided, regardless of dental insurance reimbursement. As a customer courtesy, this office will help prepare and submit patients' insurance forms as well as assist in making collections from the insurance companies. However, this dental office cannot render services on the assumption that our charges will be paid in part or in full by an insurance company. (Please understand that the amount to be paid by your particular policy is pre-determined and agreed to by your employer and the insurance company. If you have any questions about the amount the plan will pay or the treatment your plan will cover, you should refer these questions to your employer.)

Additionally, there may be a deductible, a co-insurance factor, and a yearly maximum to be considered. Most policies cover what they consider a "usual and customary fee". However, the insurance company sets these fees, and they are not always the same as the fees that may be charged in this or any office. All these factors may combine to reduce the benefits you will ultimately receive. We will do our best to see that you receive the full benefits within the structure of your particular dental plan. If your insurance company has not paid their portion of the charges within 60 days, the account will revert to your responsibility. I understand that the fee estimate listed for any proposed dental care can only be extended for a period of three months from the date diagnosed and/or examination. I further acknowledge that the proposed treatment plan can shift and/or change from the diagnosed treatment plan once treatment begins due to unforeseen circumstances beyond Dr. Wilhelm's control.

In consideration for the professional services rendered to me by the Doctor; at the providers recommendation or at my own request; I agree to pay, therefore, the reasonable value of services to Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to; by me, in writing, within the time allotted for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any future term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant permission to Dr. Wilhelm and/or Dr. Wilhelm's financial coordinator, to phone or email me at my home, cell, or at place of business to discuss matters related to treatment, financials, appointments, etc.

By signing below, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.