Financial Policies

We want to welcome you to our practice and are pleased that you selected us to serve you and your family’s dental needs. We are committed to your treatment being a positive experience. The following are the financial policies for the practice:

1. Full payment is due at the time service is rendered. Payment options include: Cash, Check, Money Order, Credit card and Care Credit.

2. We do our best to estimate your portion of the payment. However, actual charges may vary depending on the payment processed by your Insurance carrier.

3. A Minor must be accompanied by a parent or guardian for all appointments unless a written consent form is obtained. The adult accompanying the minor is responsible for full payment.

4. Missed or Cancelled Appointments: Please inform us of any cancellation of your appointment at least 24 hours in advance. Unless cancellations are received in a timely manner, the following fees will apply:

• $50.00 – Cancellation Fee for appointments scheduled for less than 1 Hour
• $75.00 – Cancellation Fee for appointments scheduled for more than 1 Hour.

5. A $35.00 dollar fee is charged for all returned checks.

6. Billing and/or late fees will be added to your account for any past due balances over 45 days. Your account will be turned over to a collection agency if the balance remains past due after 90 days. Please help us avoid this by making your payment promptly.

For Patients with Dental Insurance:

• If, at your first appointment, we are unable to verify your dental insurance or cannot obtain a list of benefits, full payment is due at the time services are rendered.
• Patients are responsible to pay their deductible and estimated co-payment at the time services are rendered. A refund check will be mailed if the insurance carrier processes a payment more than the estimate.
• We do our best to estimate your portion of the payment. However, actual charges may vary depending on the payment processed by your Insurance carrier.

As a courtesy to our patients, we will file your insurance claims and will do our best to have your claim processed. However, we must emphasize that as dental providers, our relationship is with our patients – and not the insurance company. In the state of Maryland, insurance companies are required to process claims within 30 days. In the event full payment is not received from your insurance carrier within 45 days, the remaining balance becomes your responsibility and is subject to a billing fee and an 18% APR finance charge.

Please sign your acknowledgement below. Thank you for choosing our practice.

I have read and understood the above policies and agree to abide by them.

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.