A) Prepay Courtesy (for fees over $500):
A prepayment courtesy of 6% (10% for seniors over 60 years of age) will be deducted from the total patient obligation (not from any portion due from insurance company) if the patient obligation is paid in full at the first treatment visit with cash or check.

A prepayment courtesy of 4% (8% for seniors over 60 years of age) will be deducted from the total patient obligation (not from any portion due from insurance company) if the patient obligation is paid in full at the first treatment visit with credit card.

B) Dental Fee Plan (for fees over $1,000):
With fast approval over the phone from the Dental Fee Plan, your payments can be much lower than those available through our office. The Dental Fee Plan specializes exclusively in helping patients with larger dental cases to get the treatment they want. DFP carries fixed rates between 9.9% and 12.9% and can extend terms out to 60 months. There is no prepayment penalty. We will assist you in contacting them from our office. Apply online. Link to www.dentalfeeplan.com.

C) Three Payments (for fees over $1,000):
Total patient obligation may be divided as follows: 50% due at the first treatment visit, with the remaining balance split into two equal payments, due 30 and 60 days after the first treatment visit. For any fees under $1,000, the full amount is due at the initiation of any procedure. Note: balance payments will be written at the initiation of treatment, “postdated” for 30 and 60 days.

D) Pay As You Go
You may choose to pay your entire obligation for each visit, at the visit. We will give you a breakdown of what each visit will be in advance of treatment.

E) Care Credit (Dental Credit Card)

• Interest free payment plans up to 6 months. Apply online. Link to www.carecredit.com.

F) Wells Fargo

• Interest free payment plans up to 11 months

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Forms of Payment
In order to facilitate access to the very best health care possible, you may choose from any of the following (including any combination thereof): Cash, Visa, MasterCard, American Express, Discover, Money Order, Personal Checks, or available Interest Free Fee Plans (see above).

Insurance
It is our pleasure to assist you in maximizing your insurance benefit by completing your claim forms. If your carrier is up to date (in over 70% of the cases), the claims will be transmitted via computer modem before the end of the treatment day! As a courtesy, in addition to filing the claim, if you prefer, we will initially ask you only for your estimated co-payment. Please understand that this is only an estimate, and is based upon the information available to us.
The range of benefits depends solely on what your employer wishes to purchase. Some plans cover as little as 30% or as much as 100% of dental services, with most falling in the 40% to 80% range.

Some plans base the amount of benefit on a schedule of fees arbitrarily developed by insurance companies. For this reason, you may receive a lower percentage than the reimbursement level indicated in your dental plan. For example, if you plan states that it will pay 80% of the cost of a specific treatment, it means 80% of the fee arbitrarily determined by the insurance company and not the actual fee charged by our office. The financial obligation for dental treatment is between you and our office. The insurance company is responsible to you, and not to our office. We will assist you in any way we can (including our brand new high tech “electronic claims submission”). Once your carrier has paid the claim, any difference will be due upon receipt of our statement. If for any reason, we have not received your insurance carrier’s payment 90 days after the claim, the remaining balance will be due and payable by you.

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The Last Time
"Investment in optimal health is by far your wisest long-term decision."
Q: How long will this crown (or porcelain veneer, or onlay) last?
A: So many factors influence the longevity of dental restorations that our best estimates are simply that, estimates. However, it is our pleasure to offer you what we believe to be a unique value...

This will be the LAST TIME YOU PAY FOR A CROWN on that tooth! *
Optimal health is only maintainable when provider and patient alike commit to a partnership effort...

Our Part
* If our crowns, porcelain veneers, or onlays EVER need replacement, and the tooth is still savable... as long as Dr. LeBlanc maintains his private practice in dentistry... and you do your part (below) we will at no charge:
* Replace any crown with a new crown of the same type
* Replace any porcelain veneer with a new veneer
* Replace any onlay with a new onlay
Note: If a veneered or onlayed tooth is damaged or decayed to the extent that a crown is necessary, the full fee originally paid for the veneer or onlay will be applied toward the crown. You will pay only the difference. We cannot predict if and/or when gum or nerve treatments may be required. If needed, they would require additional fees.

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Your Part
(Effective 10/1/02)
* Visit our office for a minimum of two (four, if we've recommended it due to gum condition) times per calendar year for cleanings. Note: Many of our patients still return to us after moving across the United States. If you move out of Louisiana, yet have done the rest of your part, one cleaning & checkup in our office annually will be sufficient to maintain this agreement!* Complete (in our office) all recommended treatment in the quadrant (quarter of the mouth the tooth in question is in), within a one-year period. Gum infection and bacterial decay spread from tooth to tooth and your path to optimal health requires a comprehensive approach to care.* Advise us of the need to change or cancel appointments at least 24 hours in advance. Shorter notice cancellations or changes severely limit our ability to offer another patient their most preferred time.
At the General and Cosmetic Dental Center of Acadiana, we strive to exceed your expectations.
* You will be given a copy of this agreement at your last appointment.

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