DRS. FULLER & SPENCER-FULLER
706 S. KING ST., #5
LEESBURG VA 20175
703-771-8500

Financial Policy/Basic Insurance Information

We feel that everyone benefits when there is a definite and clear understanding of our financial policy prior to treatment.

Patients with insurance: As a courtesy, our office will file insurance if current and correct information is provided. You will be expected to pay your deductible and co-payment at the time of service, and we will file with insurance for available benefits. If your insurance company denies, makes less than full payment, or takes more than 45 days to remit payment, you are responsible for the entire balance at that time. If insurance needs to be refiled due to incorrect information, we will be happy to supply you with a form so you may refile. In the event an insurance payment produces a credit balance, we will refund you promptly. We do not file seconday insurance.

It is your responsibility to monitor your benefits and annual maximum.

Patients without insurance: Are expected to pay at the time of service unless other arrangements have been made prior to your appointment.

Please note: There will be a broken appointment charge of $80, for any patient who repeatedly (more than once) cancels with less than 24-hour notice or who fails to keep an appointment.

For your convenience, we accept cash, personal checks, visa, mastercard, and discover.

If you would like for our office to file your dental insurance, we ask that you provide us with a credit card number to transfer any unpaid balance delinquent over 90 days. By signing below, you indicate that you have read and agree to the above policies.

Account number: _________________________________________Expiration date: __________

Patient/Guardian/Cardholder's Signature:______________________________________________