Patient Financial and Insurance Agreement

Welcome to our office. We are honored that you have chosen us as your dental health care provider.

Quality dental care is a financial investment. If you have insurance benefits, we will work with you to help you understand and maximize your coverage. Insurance companies and coverage can vary. Your contract for insurance benefits exists between you and your insurance carrier.

Please remember that you are ultimately responsible for your account with our office.

1. We accept payment for services by cash, check, MasterCard®, Visa®, and American Express®.
2. If you have dental insurance, we will be happy to file your claim(s) for you as a courtesy. Ultimately, what insurance does not cover is the responsibility of the patient.
3. If your insurance does not cover 100 percent of the charges, you may be billed any additional amount. You will receive an estimate of your liability prior to any appointments so that you will be financially prepared. Please remember that, regardless of insurance coverage, you are responsible for your account with our office.
4. When treatment is rendered, our staff will fully brief you on the costs and ask that your estimated copayment and deductible be paid at the time of service. We may require a deposit at the time of appointment for some services that cost more than $200. Our office will let you know of any required deposit in advance. We will file insurance claims and accept assignment of benefits. After receiving payment through your insurance, we will send a statement with any balances due or credits. We ask that payment be made within 14 days of the statement. In the event of a credit, we will promptly issue a refund. In the event that your insurance does not pay within 45 days, we ask that you make payment in full and contact your insurance company regarding reimbursement to you.
5. If you do not have insurance, your insurance pays you, or you are over your insurance limit, payment in full is expected at the time of service unless arrangements have been made in writing prior to treatment.
6. In cases of extensive treatment for which full payment cannot be made at the initial appointment, a financial arrangement may be reached. Documentation of this arrangement should be signed by the patient and office staff.
7. Fees quoted will be accepted for 90 days. In the event that clinical conditions warrant a different treatment, you will be notified of changes prior to the procedure.
8. In the event of default of payment or after 90 days, a service charge of 1.5 percent per month or 18 percent annually will be added to any outstanding balances not paid within 30 days of the current monthly billing statement. All accounts in which effort to pay is not made will be subject to collection proceedings.
9. Our office requires a 24-hour notice for any canceled appointments. A fee of $50 may be assessed for canceling an appointment without 24-hour notice.

Thank you for reviewing our financial and insurance policy. We will make every effort to explain your costs to you before treatment so we can avoid misunderstandings and focus on your dental health. If you have any questions, please ask-we are here to serve you.

I have read, understand, and agree to abide by this policy. I have been given the opportunity to receive a copy of this document.