[{"page": 1, "questions": [{"qid": 1, "labels": {"content": "

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All payment is due in full at check-in on the day of service. We accept all major credit cards, cash, check, CareCredit and Lending Club.

All emergency services, or any services performed without previous financial arrangements must be paid for in full at the time of service unless other arrangements have been made. All appointments with Dr. Sluyk and Lifeguard Sedation must be paid for in full before scheduling, no exceptions.

Dental Insurance

Patients with dental insurance understand that all services are charged directly to the patient and that he or she is personally responsible for the payment of all dental services. All estimate amounts are based solely on available insurance breakdown information, are not a guarantee of benefits, and are provided by our staff purely as a courtesy to our patients. Estimated patient cost amounts shall be collected no later than check-in on the day of treatment.

Our office will bill patient insurance as a courtesy. However, Dr. Sluyk cannot render services on the assumption that our charges will be paid by an insurance company. If the insurance carrier pays less than estimated, the patient is responsible for any unpaid balance. Treatment estimates are valid for a period of six months.

Usual and Customary Rates

Our practice is committed to providing the best care for our patients. We charge what is usual and customary for our area. Patient is responsible for payment regardless of any non-contracted insurance company's arbitrary determination of usual and customary.

A service charge of 1.5% per month (18% per annum) on any unpaid balances will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.

In consideration of the professional services rendered to me by this practice, I agree to the above financial policy. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due.

"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "left", "direction": "vertical"}}, "controlType": "paragraph", "placeholder": "Click to edit this text...", "controlTypeLabel": "Paragraph"}, {"qid": 15, "labels": {"prefixLabel": "Prefix", "suffixLabel": "Suffix", "headingLabel": "Name", "lastNameLabel": "Last Name", "firstNameLabel": "First Name", "middleNameLabel": "Middle Name"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "labelStyle": {}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}, "inputGroupStyle": {}}, "options": {"prefix": false, "suffix": false, "middleName": false}, "settings": {"required": true, "requiredInputs": ["prefix", "middle", "suffix"]}, "controlType": "fullName", "placeholders": {"prefixPlaceholder": "", "suffixPlaceholder": "", "lastNamePlaceholder": "", "firstNamePlaceholder": "", "middleNamePlaceholder": ""}, "controlTypeLabel": "Full Name"}, {"qid": 8, "labels": {"headingLabel": "Signature"}, "styles": {"main": {"paddingTop": "0rem", "paddingLeft": "0rem", "paddingRight": "0rem", "paddingBottom": "0rem"}, "headingStyle": {}, "alignmentStyle": {"label": "text-left", "alignment": "top", "direction": "vertical"}}, "settings": {"required": true}, "controlType": "signature", "controlTypeLabel": "Signature"}]}]

Consent for Services and Financial Policy