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Financial Policy

Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Patient Name

Date Of Birth

Payment Options:
We accept payment in the following forms:

Cash, Visa, MasterCard, or Discover - WE DO NOT AMERICAN EXPRESS OR CHECK PAYMENTS
Convenient Monthly Payment Plans¹ from CareCredit

Payment Scheduling:

Sparks Dentistry requires payment at the time of treatment. Our office does our best to calculate patient liability based on the information provided for us by the patient’s insurance carrier. In some instances, the insurance company may pay more or less than expected based on the information that they provided, and the patient may be responsible for the difference. A patient’s insurance policy is a contract between the patient and the insurance carrier, and any questions regarding coverage or patient liability should be directed to the insurance carrier. Please also be aware that we recommend and provide treatment based on medical necessity, not based on insurance coverage, and that the patient will be responsible for any treatment or procedure that the patient consents to if it is not covered by the patient’s insurance policy.

Sparks Dentistry reserves the right to require a preauthorization on file from the patient’s insurance carrier prior to initiating treatment, regardless of whether the insurance plan requires preauthorization. This is to protect both Sparks Dentistry and the patient, as it ensures that the insurance plan will cover and pay for their portion of the treatment. If a prior authorization is not on file, Sparks Dentistry reserves the right to require payment in full from the patient at the time of treatment, and will issue any associated refund upon payment by the insurance company. If the patient’s insurance plan does not issue preauthorization by policy, the patient may only be required to pay the estimated patient liability at time of service.

For procedures requiring multiple appointments, arrangements may be made to pay half at the first appointment, with the remainder due prior to the completion of treatment. If the patient chooses to discontinue care before treatment is complete, a refund will be determined upon review of the case.

Cancellations

Once an appointment is made, please remember this time has been reserved for you. All reminder calls and communications are done as a courtesy, and you are responsible for keeping appointments that you have made.

Below are the charges that will be made for repeated failed or cancelled appointments without prior notification of 24 hours.

• A fee of $75 is charged for patients who miss or cancel a cleaning appointment without 24 hours notice.

• A fee of $100 per hour is charged for patients who miss or cancel any other type of appointment (filling, crowns, denture, root canal, etc.) without 24 hours notice

We send statements to all patients with account balances monthly. If your balance is not settled in full following three statements, Sparks Dentistry reserves the right to send the account to a third-party service for collections, and/or dismiss the patient from the practice.

Patient or Legal Guardian Signature

Date