Financial & Missed Appointment Policies

Payment In Full

• Payment is due at time of service.
• We accept cash, check, debit, and credit (Visa, MasterCard, Discover, and American Express).

Dental Insurance

• We are a participating provider (in-network) with most insurance.
• We will gladly file a claim on your behalf with any insurance company as an out-of-network provider.
• If treatment has been pre-authorized, a co-payment is typically due at the time of service (depending on your specific dental benefits.
• Any outstanding balance after the insurance company payment has been received is your responsibility and is due immediately.

Care Credit

• Third-party, health care-specific credit card.
• Payment plans range from 6 to 24 months, with zero or low fixed interest rates.
• Fast, confidential service by phone or online. Does require a credit check and approval.

All accounts 45 days past-due are assessed a 1.5% per month finance charge (18% APR).

All accounts 90 days past-due may be submitted to a collections service.

By signing below, I agree to these terms and understand that failure to maintain my account in good standing may necessitate formal termination of the doctor-patient relationship between myself and Dr. Divya Mudumba/ Smileworks Family Dentistry PC and of my “patient of record” status at Smileworks Family Dentistry, per the doctor’s discretion.

Missed Appointment Policy

If it is necessary to cancel or reschedule your appointment, we ask that you call us at least 24 hours in advance. In order to be respectful of the needs of our patients, please be courteous and call our office promptly if you are unable to attend an appointment. This time will be reallocated to someone who needs to be seen for an urgent problem or someone who is on our wait list for an appointment.

We will call you 24 hours in advance to remind you of your scheduled appointment (please make sure we have your updated contact information). Repeated failure to attend scheduled appointments without notice may necessitate formal termination of the doctor-patient relationship between the patient and Dr. Divya Mudumba / Smileworks Family Dentistry PC and of the “patient of record” status at Smileworks Family Dentistry, per the doctor’s discretion.

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.