Thank you for choosing us as your dental care provider. Our goal is that you receive the proper and optimal treatments needed to
restore your health. The primary focus of our dental practice is to provide the highest quality dental care in the most gentle, efficient and
enthusiastic manner. However, we ask that all patients pay for their treatment in full on the day of each visit to our office unless prior
arrangements have been made. The following is our financial policy.
Dental Insurance:
If you have dental insurance the practice will work with you to maximize your allowable insurance benefits and will assist you in making
necessary filings with your insurance company. It is understood that the practice will diagnose treatment based on your dental health
and not your insurance coverage. It is further understood that, since your insurance is a contract between you and your insurance
company/employer, the practice cannot assume responsibility for coverage or other determinations made by your insurance company
and that you will be responsible for timely payment for all treatment received from the practice regardless of your insurance status.
Please remember you are fully responsible for all fees charged by this office regardless of your insurance coverage. We will send a
monthly statement. Most insurance companies will respond within 3-4 weeks. Please call your insurance company if your statement
does not reflect payment within this time frame. Any remaining balance after your insurance has responded is your responsibility. Your
prompt remittance is appreciated.
If payment is not received within 60 days, the balance becomes your responsibility. You, the patient, will have to contact your insurance
company to determine why payment has not been made.
Your complete dental insurance information must be presented at the time services are provided. It is your responsibility to make sure
we have accurate insurance carrier information and billing information. Diagnosis and services are carefully documented to comply with
federal law. Under no circumstances will these be changed, altered or falsified in order to obtain coverage by insurance.
Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.
Past Due Balances: Account balances over 60 days will be charged interest at a rate of 1.5% per month, or 18% annually.
Medical Insurance and 3rd Party Insurances: Medical Insurance and Auto Insurance will be billed as a courtesy to you. If no payment
is received within 30 days, the balance is your responsibility and is due.
Dental Care Financing:
We have arranged special financing with several outside financing companies to reduce the financial barriers
for our patients in receiving optimal care. We do not carry account balances in office.
Estimates:
Fees quoted for treatment will remain in effect for 90 days, and thereafter are subject to change without notice. In the event
clinical conditions warrant a modification in treatment, you will be notified of modifications in treatment and the associated fees prior to
proceeding with the modified treatment. With proper diagnosis and a timely treatment plan, most estimates we provide are accurate.
For patients who have elected sedation, the doctor may discover conditions requiring different dental treatment from that which was
planned, those additional procedures that are necessary will be performed in the exercise of professional judgment when it is
impossible to discuss the treatment with the patient. All efforts will be exhausted to contact your legal representative prior if you so wish.
Children: the parent or guardian who brings the child into the office for dental treatment is financially responsible regardless of dental
insurance or legal responsibility another parent or guardian may have to this.
Returned Checks:
A fee of $30.00 will be charged for any returned checks on your account and full payment along with fee must be
paid by cash, VISA, MasterCard or Discover card within 10 days.
Missed Appointments:
Unless cancelled, at least 24 hours in advance, our policy is to charge a $50.00 missed appointment/late
cancellation fee. Please help us serve you better by keeping scheduled appointments.
Many times, a simple telephone call will clear any misunderstanding. Our office staff is always willing and available to discuss
billing matters with you at any time; we know that you will agree that your clear understanding of our financial policy is important to our
professional relationship.
In the event of default, I agree to pay legal interest on the indebtedness, together with such collection cost and reasonable attorney
fees as may be required for collection of this note. For the mutual convenience of you and the practice, it is understood that this
executed copy of the Financial Policy also shall cover your dependent children who are patients of the practice.
Assignment of Benefits:
I hereby guarantee payment of all charges incurred at this office. I hereby assign and direct to pay any and all benefits for dental
services under this claim directly to the provider. I hereby authorize the release of any medical information requested by the insurance
companies with the above assignment.