Our goal is to assist you in the financial aspect of your account with the same quality and professionalism that our dental care provides. Your review of our financial guidelines at this time will help greatly to avoid future misunderstandings.
Our relationship and our contact with you is that of Dentist-Patient. We do not provide services to insurance companies and have no responsibility to assure that the insurance company is supportive of your dental care.
Although we are here to help you, any contract that exist between you and your insurance company for dental care reimbursement does not obligate us to comply with the provisions of your policy. We will assist you in filling your claims. Services rendered to you, which make you the responsible party. If you are unsure of any of the specific requirements of your insurance company, please contact them directly.
Often insurance companies will use the term “usual and customary”or similar such language when denying charges for dental care.The implication is that the doctor charges too much for a given procedure or visit. Universal “usual and customary” fee schedules do not exist.The amount an insurance company reimburses for a procedure will vary with the company, the type and quality of the policy. Our fee schedule is the same for everyone.
Payment is expected at time of service for all procedures not covered by your insurance.When payment from the insurance company has not been received within 60 days of treatment, it will be your responsibility to contact the insurance company and to send office payment in full at that time. We accept cash, check, all major credit cards as forms of payment. In the event of account default, you will be responsible for said balance as well as any collection costs, including attorney and court fees. A delinquent account creates an uncomfortable environment for everyone.
We reserve time with the doctor or hygienist to serve your dental needs. *If you are unable to make your reserved time, we require at least 24 hour notice to avoid a minimum charge of $50.00 per hour scheduled.* We need time to care for each of our loyal patients. This broken appointment policy is out of courtesy to ALL of our patients who need appointments.
By signing this agreement, I understand the policy as defined above and agree to abide by it.
(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.)