Office Policies and Financial Agreement

  • It is our policy to have a definite agreement between you, the patient, and this office concerning the payment of fees for services rendered. Prior to treatment, you will be advised of an estimated cost of treatment. If you have dental insurance, we will do our best to estimate your out of pocket expenses based on the information we gather from your insurance company. If you require more than an estimate, please let us know, and a predetermination of benefits may be sent to your insurance company on your behalf. This requires the insurance company to inform our office and you exactly what they will pay. This does delay treatment, but it is a service we offer to remove any uncertainty about your out of pocket costs. For your convenience, we accept Cash, Check, Visa MasterCard, & Care Credit. All emergency dental services or any dental services performed without previous financial arrangements with the financial staff must be paid for at the time of service.

    Patients Not Covered By Dental Insurance: Payment in full is expected when services are rendered.

    Patients Covered By Dental Insurance: We will be happy to complete the necessary forms for your dental claims as a courtesy to you. You are responsible for the entire balance regardless of your insurance coverage. We are a thirdparty providing dental services to you and your family. This office requires that you are responsible for your co-payment and deductibles at the time of service. We will allow 60 days for your insurance earner to reimburse us for services provided. If your insurance carrier fails to issue reimbursement within that time frame, the outstanding balance will be your responsibility and a statement will be sent.

    We understand that situations arise in which you may need to cancel or change your appointment due to unforeseen circumstances. We kindly request you give us as much notice as possible if you must cancel your appointment. We would prefer to have 48 hours notice so that we may attempt to arrange for another patient to be seen at that time. We do not double book appointments and your appointment time is reserved exclusively for you.

    If an appointment is cancelled, without at least a 24 hour notice, you will be charged a $75.00 cancellation fee. Patients that miss their appointment without calling to cancel will be considered a “No Show” and will also be charged a $75.00 fee. These fees will not be covered by your insurance company, and must be paid before the next appointment is made.

    We value our professional relationships and believe effective communication and mutual respect is of the utmost importance. Any questions about this policy may be directed to the front office staff.

    In consideration for the professional services rendered to me, I agree to pay for those services in full. I agree that a $10.00 late fee per month can be added to any account balance that is over 90 days. In the event that my account is turned over to a collection agency, I agree to pay any court costs and attorney fees which may be associated with my account. I grant my permission for you to telephone me at home or work to discuss matters related to this form.

  • Date Format: MM slash DD slash YYYY