The following is a statement of our Financial Policy. This form must be read and signed prior to any treatment.
Patients without dental insurance: Full payment is due at the time of service. Payment arrangements may be coordinated in advance of appointments. We accept cash, checks, or credit cards (Visa/MasterCard/Discover)
Patients with insurance plans: Depending on the type of treatment offered, 20-50% of the total appointment cost is to be paid at time of service. The balance is your responsibility whether your insurance company pays or not. Your insurance policy is a contract between you and your insurance company. We are not a party in that contract. Please be aware that each insurance company analyzes their benefits differently. However, you are responsible for total payment of services provided to you in our office regardless of any insurance company’s determination.
Minor Patients: The parent, guardian, or adult accompanying a minor patient is responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card or payment by cash or check at time of service has been verified.
Missed Appointments: Unless cancelled at least 24 hours in advance, our policy is to charge for missed appointments at the rate of a normal office visit. Please help us to serve you better by keeping scheduled appointments.
Acceptance of Financial Policy: Thank you for your review of 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 the terms of this Financial Policy.”