Payment, in full, is due at the time of service. We accept cash, personal check, Visa/Mastercard or Discover.
Our office does NOT participate in any insurance plans (HMO, PPO, etc…). As a service to our patients we will process and submit PPO dental insurance claims upon your behalf. You must have with you your Insurance ID card and a signed and completed insurance form complete with mailing address. Patients who claim to have insurance but do not produce the necessary documentation will be considered by this office to be a non-insured patient.
All deductibles and co-payments are due at the time of the visit. If we do not receive payment from your insurance company after 60 days, you will be billed for the outstanding balance. You will be responsible for any portion of fees not paid by your insurance company.
Insurance is a contract between you and your insurance company. We will strive to help you receive your maximum benefits by providing factual information as necessary. However, we will not become involved in disputes between you and your insurer. You are responsible for timely payment of your account.
We do our best to remind patients of their appointments 24 hours in advance by telephone and/or email. Patients who fail two successive appointments without notice to this office will be charged a $50.00 missed appointment fee. Patients who continually fail appointments without notice will be asked to seek care elsewhere. We realize your time is valuable and try our best to be punctual.
Patients who have an outstanding balance will be billed on a 30-day billing cycle. Any money due in excess of 30 days will be subject to a service charge of 1 ½% monthly. Accounts due over 90 days will be subject to collection procedures and any additional fees required in order to collect those overdue accounts.
Thank you for taking the time to review our office policy. If you are unclear about any of the information and how it pertains to you, please ask one of us prior to signing this form.
I have read this form in its entirety and any concerns I had were addressed: