As validated by my signature on the bottom of this form, I understand and agree that: 

All patient balances are due immediately after treatment is rendered. 

Should a balance accrue on the account, a statement will be sent and payment is to be made, in full, by the date on the statement. Accounts that are more than 90 days overdue may be turned over to a collections agency for recovery of fees for treatment rendered.

 

We have reserved your appointment time specifically for your child.  As a courtesy to other patients who may gladly utilize your appointment time should you cancel, we require 24 hours' notice for a cancellation.  If you fail to inform us of your inability to attend your appointment, there is a $35 failed appointment fee assessed per appointment.

A returned check fee may also be applied and must be payable from you for each check payment returned to us by your bank. 

Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by the our office, not an obligation. Ultimately, you are responsible for any treatment that is unpaid by the insurance provider. 

If there is dental insurance on the account, the office has established the patient balance based on the information I have provided. Final treatment payment is subject to the terms and conditions of my insurance provider on the date of service. As such, until payment is received from my insurance provider, no patient payment is final. 

Estimates and treatment plans are based upon information gained from the examination. As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. This is a preliminary estimate only and lab charges (if applicable) have been estimated and included total. 

Estimates do not take into consideration any money that was billed toward my financial maximum or treatment limits that may have been used at other dental offices. 

A submission to my insurance provider will be sent to determine an approximate final investment. However, it is an estimate only. Final insurance splits may be adjusted upon receiving the predeterminations. Predeterminations from my insurance provider(s) are NOT a guarantee of payment. 

As with any dental treatment, there may be unforeseen treatment adjustments and/or complications. The office will make an effort to anticipate any changes in the treatment plan and advise me at that time. However, such events are unpredictable. Likewise, the timing or spacing of appointments may need to be modified as needed to accomplish the best result possible. 

Emergency care after office hours may incur an additional fee to account for opening the office, bringing in support staff, etc.

I have read, understand and agree to the above financial policy for payment of professional fees. I understand that I am ultimately responsible for all fees for services rendered to me and/or my family.