Online Registration Forms

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Patient Information

Billing Information

Primary Insurance

Secondary Insurance

Patient Health History

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Medications

Women Only

Dental History Information

Financial Policy

We are committed to providing you with the best possible care, and we are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibility.

PAYMENT

Payment is due in full at the time services are rendered, unless prior financial arrangements have been made. For convenience, we accept payment in the form of cash, checks, credit and debit cards.

REGARDING INSURANCE

We file insurance claims as a courtesy to our patients and our office is dedicated to helping our patients maximize their benefits. Upon verification of coverage, we will complete your claim form so that you can be reimbursed by your insurance company to the extent of your coverage. Some carriers pay a fixed allowance for a procedure, while others pay a percentage of the fees charged. It is your responsibility to pay deductibles, co-payments and any balance not paid by the insurance carrier. Insurance is a contract between you and your insurance company. We are not a party to this contract in most cases; therefore, you are solely responsible for your benefits and eligibility information. (We will inform you if we are a party to your insurance contract, and will handle your claims according to our agreement with the insurance company, if one exists.) We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, "usual and customary" charges, etc., other than to supply factual information as necessary. You are ultimately responsible for the timely payment of your account.

Please note that any insurance payment estimates provided as part of your treatment plan are solely estimates generated by our practice management software. These are NOT guarantees of payment. For more accurate information on insurance payment towards any specific treatment, you may inquire directly with your insurance carrier or request the processing for a pre-determination of benefits. Please understand that most insurance carriers will also not guarantee benefits presented in a pre-determination, and this process can often delay treatment for several weeks. If your insurance company has not paid the FULL BALANCE within 45 days, you have 15 days to pay the balance. If your insurance company pays more than the balance due, we will send a refund check to you immediately.

DELINQUENT ACCOUNTS

Late Payment Charges (1.5% per month) are added to unpaid accounts after 60 days from date of service. There will also be a $40 fee for any returned check. In the case of default of your account you will pay collection costs, interest on the unpaid balance until paid in full, and attorney fees incurred in attempting to collect on your present and future account balance. Collection accounts may be reported to credit service bureaus, when appropriate.

MISSED APPOINTMENTS

Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. All major treatment appointments will require a 10% deposit at time of scheduling, which will either apply toward the procedure fee(s) or be forfeited for a cancellation with less than 48 hours of notice. Please help us serve you better by keeping your scheduled appointments.

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