Payment Calculator Financial Calculator Step 1 of 4 25% Patient InfoName First Last Today's Date MM slash DD slash YYYY Credit RatingA - No Downpayment - 120% of Treatment LengthB - 10%-20% Down - 100% of Treatment LengthC - 15% - 25% Down - 90% of Treatment LengthNR - 15% - 25% Down - 90% of Treatment LengthTreatment TypePHASE IPHASE I - CLEAR ALIGNERPHASE I CLASS IIIPHASE I CLASS IIIPHASE IIPHASE II - CLEAR ALIGNERFULL TREATMENTFULL TREATMENT - CLEAR ALIGNERPRE-PHASE ISIMPLE PHASE IIPHASE I/PHASE II ComboFULL CLASS IIIFULL ADULTFULL ADULT - CLEAR ALIGNERFULL SURGICALRE-TREATLITETreatment Amount Estimated Months in TreatmentDiscountsDiscount #1 - TypeNoneTeacherFamily - 2nd & 3rd MemberMilitaryMeyer Dana Staff & Families - After 6 mo of EmploymentNon-Immediate Dr. Meyer & Dr. Dana FamilyClergy - Dr. DiscretionCalvary Christian SchoolProfessional DiscountDoctor DiscountDiscount #1 - AmountDiscount #2 - TypeNoneTeacherFamily - 2nd & 3rd MemberMilitaryMeyer Dana Staff & Families - After 6 mo of EmploymentNon-Immediate Dr. Meyer & Dr. Dana FamilyClergy - Dr. DiscretionCalvary Christian SchoolProfessional DiscountDoctor DiscountDiscount #2 - AmountDiscount #3 - TypeNoneTeacherFamily - 2nd & 3rd MemberMilitaryMeyer Dana Staff & Families - After 6 mo of EmploymentNon-Immediate Dr. Meyer & Dr. Dana FamilyClergy - Dr. DiscretionCalvary Christian SchoolProfessional DiscountDoctor DiscountDiscount #3 - AmountFee After DiscountCurrent Estimated CostIs the Patient Paying in Full? Yes No Paid in Full Discount AmountFee After PIF DiscountInsuranceDoes the Patient Have Insurance? Yes No Less Estimated InsuranceInsurance Provider Initial PaymentPayment FrequencyBi-WeeklyMonthlySemi-AnnuallyAnnuallyDoes the Patient Have Additional Insurance? Yes No Less Additional Estimated InsuranceAdditional Insurance Provider Additional Insurance Initial PaymentAdditional Insurance Payment FrequencyBi-WeeklyMonthlySemi-AnnuallyAnnuallyEstimated CostEstimated Responsible Party PortionEstimated Responsible Party Portion (PIF) Office Payment OptionsTo offer our patients the most flexibility, we offer multiple options for payment. Payment arrangements will be made with a down payment and automatic monthly payments with no interest.Option #1You'll make one down payment of $800 and monthly installments (automatically deducted) for 22 months.Option #2You'll make one down payment of $500 and monthly installments (automatically deducted) for 24 months.Option #3You'll make one down payment of $177 and monthly installments (automatically deducted) for 26 months. Down Payment & Payment OptionsDown Payment AmountFinal Responsible Party PortionFinal Responsible Party Portion (PIF)Number of MonthsEstimated Monthly PaymentEPP Yes No Number of Additional MonthsEstimated Monthly Payment (Extended Payment Plan) Unpaid BalanceUnpaid BalanceTotal cost minus the down payment.Unpaid Balance (Extended Payment Plan)Total cost minus the down payment, for an extended payment plan.How Will the Patient Pay the Down Payment?Credit CardDebit CardCheckCashFirst Payment Due MM slash DD slash YYYY Notes for Treatment CoordinatorSignature
