Our goal is to provide you with the best possible dental care. If you have dental insurance, we will be happy to help you receive maximum allowable benefits. In order to successfully achieve this goal, we need your assistance and understanding of our financial policy
We will happily assist you in completing and submitting your insurance claims. You must provide us with all insurance and subscriber information. If this information is unavailable, please understand that full payment will be collected from you at the time of your visit and a claim will be submitted to your insurance company once all of the necessary information is received
Submission of insurance and acceptance of the assignment of benefits is not a guarantee of payment. While we do our best to give you accurate estimates regarding your patient portion and submit for pre-determinations, please understand this is only an estimate and it is important for you to know what your insurance covers, as every policy is different. Should your insurance pay less than anticipated, you are responsible for the difference. Payment is due at the time of service and financial arrangements should be made prior to treatment. We reserve the right to charge a late fee of $50 to any unpaid balances beyond 60 days without payment arrangements. If collection services are required, you will be responsible for all collection costs and any other fees incurred
All appointments canceled without 24 hours notice are subject to a $50 cancellation fee. As a courtesy to you, our office makes every effort to confirm your appointments; however, any unconfirmed appointments will be removed from our schedule on the morning of if we do not hear from you.
I have read the above. I fully understand the terms and conditions set forth. I authorize the release of any information relating to my dental claim. I fully understand that I am responsible for all costs of dental treatment regardless of insurance.
We accept cash, checks, Visa, Mastercard, American Express, Discover, and Care Credit.
In an effort to conserve paper we have displayed the HIPPA Consent form in our waiting room for you to review or you can view it on our website (https://www.cjdentalarts.com/new-patients). If you would like a copy of your own please ask at the desk or print it from the website. I have received notice of this office’s HIPPA Privacy Practices
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