Thank you for choosing us as your healthcare provider. The following is a statement of our office policy which we require you to read and sign prior to treatment.
Full payment is due at time of service
We accept cash, checks, Visa, Discover, Mastercard and AmEx
We also offer Care Credit
As a courtesy to our patients, we will be happy to submit an insurance claim and any additional information required from your insurance carrier to assist you in receiving your maximum insurance benefit. However, in the event of an unpaid benefit by your insurance company, you WILL be responsible for the balance in full. Your insurance is a policy contract between you and your insurance company; we are not a party to that contract. If you have questions about why your insurance has paid a certain amount or disallowed the amount, we encourage you to call your insurance. If your insurance has not paid your account in full within 45 days, the balance is due in full. All copays and deductibles are due at the time of service. Some procedures may not be covered by your insurance; therefore, you may choose to verify with your insurance before treatment is started. If you are covered by more than one dental insurance company, please do not assume that you are covered 100%, some insurance companies do not coordinate benefits and/or have waiting periods on some procedures. It is your responsibility to verify this information. Please provide our office with all employment insurance information before you arrive for your appointment so we can properly submit your claims.
Usual and Customary Rates
You are responsible for payment regardless of an insurance company’s arbitrary determination of usual and customary rates.
The adult accompanying a minor (or guardians of the minor) is responsible for full payment.
Unless canceled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of $50.00. Please help us serve you better by keeping scheduled appointments.
I have read the office policy and al of my questions and concerns have been addressed. I understand and agree to this 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.