Thank you for choosing us as your dental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy, which we require that you read and sign prior to treatment.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE
Your insurance policy is an agreement between you and the insurance company; we are not a party to that contract. We ask that all patients be directly responsible for all charges. Your estimated co-payment and deductibles will be due at the time of service. We are happy to submit the claims necessary to help you receive the full benefits of your coverage; however, we cannot guarantee any estimated coverage. All account balances not paid by the insurance company are the responsibility of the patient. We are in-network with most of the Dental Insurances; however, we are not in-network with Medical Insurances and we do not do Medical Billing in our office.
We accept Cash, Visa, and MasterCard. In addition, we offer Care Credit, a patient payment program offering a full range of Deferred Interest, and Extended Payment Plans for treatment. We don’t accept checks.
We try to remind appointments by phone call, text, or email prior to the appointment-but please do not depend on this courtesy. The time has been reserved exclusively for you. If you need to change your appointment, we require 48-hour notice. Our office policy is that $50 will be charged upon a FAILED appointment. We require %20 of the total service fee to be pre-paid to schedule a new appointment after two failed appointments or short notice cancellations.
In the course of treatment, it may be necessary to take a photo of your teeth or tissues for diagnostic, restorative, or educational purposes. I agree to the release of these images. These images will not contain any identifying facial features or information
THANK YOU FOR READING OUR FINANCIAL AND OFFICE POLICY. PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS.
I have read, understand and agree to the above financial and office policy.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.