Dr. Mark Com strives to offer convenient payment options while at the same time maintaining the high standard of comprehensive dental care that our patients deserve. At the onset of your treatment, we will provide you with an estimate of your total treatment costs. Our goal is to help you afford your dental choices.
Please understand that this will only be an estimate and is valid for 30 days. Some or all of your treatment may not be covered due to plan limitations that have not been disclosed to us. It is your responsibility to contact your insurance company to determine which services are covered under your plan. If your dental plan does not pay the amount we have estimated, the balance is your responsibility. Should the need for additional treatment arise during the course of the original treatment plan, the fees could change. Be assured that we will notify you of fee changes and obtain your approval prior to proceeding with treatment.
To demonstrate our appreciation for patients who are prompt with full payment, we will extend a five percent (5%) reduction. This applies only to treatment plans of $500 or more. We are unable to offer the 5% discount to Care Credit accounts and PPO accounts.
I accept full financial responsibility for my account and for all dentistry performed upon my dependents in this dental office. I understand that it is up to me to confirm my insurance eligibility, waiting periods, and benefits. I also understand that this office cannot guarantee my insurance status in any of these areas.
Any insurance estimate or information given to me by this office is not a guarantee of actual insurance payment. I also understand that any insurance claim not paid in full after 60 days will become my
responsibility to pay at that time. In order to ensure that my account is kept current, I will allow this office to keep my credit card account number on file. This account will only be used if my account becomes delinquent after 60 days for any reason.
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