Patient Financial Form

Contact our Shelby Township dental office today to learn more about our dentists or to request an appointment.

  • Financial Policy

    We, the staff of Frank P. Ruffino D.D.S., PC, thank you for choosing us as your dental/healthcare provider. We consider it a privilege to serve your needs and look forward to doing so. We are committed to providing you with the highest level of care and to building a successful provider-patient relationship with you and your family. We believe your understanding of our patients' financial responsibility is vital to that provider-patient relationship and our goal is to not only inform you of the provisional aspects of that financial policy, but also to keep the lines of communication open regarding them. If at any time you have any questions or concerns regarding our fees, policies or responsibilities, please feel free to contact our office at 586.799.4240.

    We believe this level of communication and cooperation will allow us to continue to provide quality service to all of our valued patients. Please understand that payment for services is an important part of the provider-patient relationship. If you do not have insurance, proof of insurance, or participate in a plan that will honor an assignment of insurance benefits, payment for services will be due at the time of service. If eligible, we have extended payment plans that are financed through Care Credit.

    We make payment as convenient as possible by accepting cash, money order, MasterCard, Visa, American Express, Care Credit and in-state checks. A $35 service fee will be charged for all returned checks. Additionally, you may authorize us to keep your credit card on file for your convenience, knowing that we adhere to the highest level of information security. Should payments not be received in a 60 day period, collection proceedings will begin through Transworld Systems.


    Please remember that your insurance policy is a contract between you and your insurance carrier. We will, as a courtesy, bill your insurance and help you receive the maximum allowable benefit under your policy. We have found that patients who are involved with their claims process are more successful at receiving prompt and accurate payment services from their insurance carrier. We do expect patients to be interactive and responsible for communicating with your insurance carrier on any open claims. It is your responsibility to provide and update all necessary information regarding your insurance policy. Even a preauthorization of service does not guarantee payment from your insurance carrier. We also require photo identification when accepting insurance information. In addition, it is the patient's responsibility to know if our office is participating or non-participating with their insurance plan. Failure to provide all required information may necessitate patient payment for all charges. When insurance is involved, we are contractually obligated to collect co-payments, co-insurance and deductibles, as outlined by your insurance carrier.

    Please be aware that out-of-network insurance carriers often prohibit assignment of benefits and may try to limit their financial liability with arbitrary limits, exclusions or reductions, such as reasonable and customary or usual and prevailing reducions. Our fees are well within such ranges and although we will assist in the filing of an appeal if these limitations are imposed, you as the guarantor are responsible for all out-of-network fees. If we are not contracted with your carrier, we will not negotiate reduced fees with your carrier.


    An interest charge of 4% will incur if a balance remains unpaid after 90 days.

    Missed Appointments

    We require notice of cancellations 24 hours in advance. This allows us to offer the appointment to another patient. If you fail to keep your appointment without notifying us in advance, a missed appointment fee will apply. These fees are typically $60, but not to exceed one-half of the cost of your scheduled appointment. Repeated missed appointments without notifications may cause you to be discharged from the practice so that we can provide care to other patients.

    We realize that temporary financial problems may affect timely payment of your account. If this should occur, please contact us for assistance in the management of your account. Our goal is to provide quality care and service. Please let us know immediately if you require any assistance or clarification from anyone within our business.

    I have read and understand the above financial policy. I agree to assign insurance benefits to whenever applicable. I also agree, in addition to the amount owed, I also will be responsible for the fee charged by the collection agency for costs of collections, if such action becomes necessary.

    Please list spouse and any dependents association with this account.

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