Thank you for choosing us as your dental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.
FULL PAYMENT IS DUE AT TIME OF SERVICE.
WE ACCEPT CASH, CHECKS, CARE CREDIT, VISA, MASTERCARD and DISCOVER.
The adults accompanying a minor and the parents or guardian of the minor are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved Care Credit plan, Visa, MasterCard, Discover, or payment by cash or check at time service has been verified.
We may accept assignment of insurance benefits after your second visit. However, we do require 50% of the bill to be paid at time of service. The balance is your responsibility whether your insurance company pays or not. We cannot bill your insurance company unless you give us your insurance information. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event we do accept assignment of benefits we require that you pay your portion at the time of service. If your insurance company has not paid your account in full within 30 days, the balance will be automatically transferred to your portion of the account and will be due immediately. Please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered reasonable and necessary under your insurance benefit plan.
Unless cancelled at least 48 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. This charge is the sole responsibility of the patient and will not be billed to the insurance carrier of any other third party.
A finance charge of 1.5% per month will be added to account balances 30 days or more past due. We reserve the right to charge interest in the amount of 18% as provided by state law.
Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.
I have read the Financial Policy. I understand and agree to this Financial Policy.