Required at each visit:
Provide current personal information at each visit
Provide current insurance card and drivers license at each visit
Payment of any outstanding balance
Payment for today’s visit (Fees / Co-pays / Deductibles)
 
Insurance Plans:
                Your insurance plan is a contract between you, your employer, and the insurance company.  We are not a party to that contract.  While the filing of insurance claims is a courtesy that we extend to you, all of the patient charges are your responsibility from the date that the services are rendered.  We do ask that you pay the estimated charges at the time of service.  We will bill your insurance for their portion of payment, and any overpayment will be refunded to the responsible party.  Also, additional payment needed after the collection of insurance or denial of insurance benefits will be billed to the responsible party and are due 30 days from the statement date. 

Methods of Payment Accepted:
Cash/Check, Credit Cards – We accept Visa, MasterCard, Discover and American Express.

Financing Available (Care Credit) – Please ask us about the options available to create a plan to complete your dental treatment.  Please ask us if discounts may be available.

 
All balances over 90 days overdue are subject to an 8% finance charge, with a maximum yearly finance charge of 24.99%. The minimum monthly finance charge will be $5.00.

There will be a $50 cancellation fee for appointments cancelled less than 48 hours in advance. There is a $30 returned check fee due to bank charges to our office.

 

Thank you,

 Justin Shiflett, DDS


*Fees and percentages are subject to change with out notice