Appointments are reserved exclusively for you, our patient. As a courtesy, you may receive an email or text message to confirm the appointment. Appointments can be canceled within 48 hours of the appointment time. Patients with failed appointments, or less than 48-hour notice of the cancelation, will be charged a minimum of $75 per appointment, depending on the block of time scheduled. These fees cannot be waived. Two failed appointments qualify the patient to be dismissed from the practice. Appointments requiring more than 90 minutes of the doctor’s time may require a $250 non-refundable deposit.
Dental insurance benefits are designed to share the cost of your dental care. Your plan may not cover the total cost of treatment, leaving a copayment. Our benefit team will give you the best estimate possible for treatment cost, but cannot predict the exact level of coverage for a particular procedure.
Patients with proposed dental treatment will be given a treatment plan with fees, copays and insurance benefits to be signed prior to any treatment. The treatment plan is an estimate only.
A Treatment plan does not guarantee payment from the insurance company. It is the responsibility of the patient to be aware of the benefits provided by their insurance, along with its limitations an exclusions.
If the insurance denies coverage or pays for less than the estimated portion, the patient is responsible for the remainder of balance within 30 days of notification.
An overdue balance of 30 days will be subject to a billing charge of $45 each monthly cycle. Patients with an outstanding balance past 90 days will be referred to the credit bureau and collection service.
Patients in collections can only be seen for an emergency until the overdue charges have been paid off, and the balance is at $0.
All patients using insurance benefits must present both an insurance card and a state issued form of identification. If we cannot verify insurance benefits, services will be charged at a full fee to the responsible party at the time of service.
All sales are final.
All copayments are due at the time of service.
I consent for photographs/video to be taken and along with my record to be used in dental journals, textbooks and electronic publications or for teaching purposes. These photographs will be used without identifying information such as my name.
I agree to communication in the form of txt, email or video related to my procedure(s) via cell phone number provided on my information sheet.
I acknowledge I have have read and understand this form and have been given a copy today.