Our office is committed to providing each patient with the best care possible. We have established the following guidelines to assist you in understanding our financial policy. We feel that a clear financial policy is very important in helping you obtain the service and quality you deserve.
Fees are quoted prior to treatment and are valid for 3 MONTHS.
Once a quote is given, the fees will not change except as follows:
If the patient's inability to keep an appointment results in the necessity for a change to the recommended treatment.
If the procedure becomes more complex due to undetectable decay or fracture.
Payment is due at the time of services; we do not bill.
A deposit shall be requested to reserve appointments of 1 hour or more.
A 5% book-keeping courtesy may be offered for pre-payment in full prior to beginning the complete accepted treatment for those WITHOUT insurance benefits.
No interest and low interest plans are available upon approval with 3rd party financing programs through CARE CREDIT.
Our office is a participating provider with most dental insurance plans. It is your responsibility to know your insurance benefits. As a courtesy, we will file your insurance claims on your behalf. However, your insurance is a contract between you and your employer and we cannot guarantee payment. We will estimate the portion your insurance will pay on your plan.
THIS IS ONLY AN ESTIMATE. You will be responsible for the total costs of services not covered by your insurance, in addition to any applicable yearly deductible, ineligible services, co-payments and balances at the completion of treatment.
We require 24-48 hours advance notice if you will be unable to keep your appointment.
Should you fail to provide is with this courtesy, we will charge your account $50 for each scheduled hour.
Once an appointment has been made, please remember this time has been reserved specifically for you.
Any and all returned checks shall be subject to a return check fee of $35.
Any unpaid balances on accounts older than 60 days shall be assessed an interest charge of 1.5% per month (18% annual percentage rate).
If it becomes necessary to take legal action to enforce this policy or to collect any fees for professional services rendered according to this policy, the patient and/or financially responsible party shall be liable for all related costs and fees including attorney fees, court costs, and collection agency fees.
My signature below indicates that I have read and understand the Financial Policy of this office.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.