Thank you for choosing us as your dental health care provider! We are committed to providing excellent dental care in a relaxed and caring environment. The following is a statement of our Financial Policy for you to read and sign prior to your treatment.
FULL PAYMENT IS DUE AT TIME OF SERVICE We accept: Cash, Checks, Visa, MasterCard, Discover, American Express and Care Credit Convenient Payment Arrangements for Major Restorative Treatment
We require deductibles and co-pays to be paid at the time of service
Your insurance policy is a contract between you and your insurance company. However, as a courtesy to you, we will submit your bill to your insurance company for services rendered
If your insurance company has not paid the total claim within 90 days from the date of your treatment, the balance will be billed to you. Please be aware that we may receive only a partial amount of what was billed to the insurance company. You will be responsible for amounts the insurance company has determined as ineligible or not covered in full.
USUAL AND CUSTOMARY RATE: Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s determination of usual and customary rates.
MINOR PATIENTS: The parent or guardian of the minor is responsible for full payment. If an adult is not present, it is preferred that the payment be sent with the patient
CANCELLATIONS AND MISSED APPOINTMENTS: We require 48 hours' notice if you need to reschedule your appointment. This gives us time to contact another patient who may be waiting for an appointment. If given less than 48 hours notice, a cancellation/missed appointment fee of $125.00 for (hygiene) and a cancellation/missed appointment fee of $225.00 for Dr. McCune will be charged. However, we do realize there may be an emergency or sudden illness that makes notifying us in a reasonable time difficult.
Thank you for reviewing our Financial Policy. Please let us know if you have any questions or concerns.
I HAVE READ AND UNDERSTAND THE ABOVE STATED FINANCIAL POLICY
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