Financial Policy

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Thank you for choosing us as your dental health care provider. We look forward to assisting
you in attaining optimum oral health.

Please understand that payment of your bill is considered a part of your treatment. The
following is a statement of our financial policy, which we require that you read and sign
prior to any treatment. All patients must also complete our Patient Information Form as well
as your insurance form, if required by your plan, before seeing the doctor.

Full Payment Is Due At The Time Of Service unless other financial arrangements have
been made in advance. We accept cash, check, American Express, Master Card, Visa, and Discover cards.
Other financial services are available through Care Credit.

A monthly billing fee of 1.5% or $5.00, whichever is greater, will be added to all accounts
that remain unpaid after 60 days. If it becomes necessary to use other means for collecting
payment, the patient is responsible for any and all costs, fees, and attorney fees incurred.

Regarding Insurance
Our office requires that you pay your deductible and co-payment, if applicable, at the time
of service. While every effort will be made to maximize your insurance benefits, the
balance is your responsibility, whether your insurance company pays or not. If your
insurance company has not paid your claim within 60 days, the balance will be automatically
billed to you. Please be aware that some and perhaps all of the services provided may be
non-covered services and not considered reasonable and necessary under your policy.
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We will file insurance claims for you if you bring all insurance information and a completed
insurance claim form, if required by your plan. Information regarding insurance benefits
is the responsibility of the patient. Estimates given by our office are not a guarantee of
benefits. We cannot be held responsible for the benefits paid, or not paid, by your
insurance company.

Emergency Care
All emergency care patients are expected to remit payment at the end of the appointment.

Missed Appointments
Unless canceled at least 24 hours in advance, our policy is to charge for missed
appointments at the rate of a normal office visit. Please have the courtesy to give us at least
48 hours notice so that we may help serve other patients wanting treatment.

Thank you for understanding our Financial Policy. Please let us know if you have any
questions or concerns.

I have read this Financial Policy, and understand and agree to this Financial Policy.

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