To prevent any misunderstandings and maintain a positive relationship with you, the following is the practice’s financial policy. We thank you for your understanding and cooperation with these policies. After having read the policies, please sign at the bottom.

 

● Out-of-network insurance / Payment due at the time of service – We request that you make your payment on the date that the services are rendered. We accept cash, checks, credit cards, and debit cards.

 

● Insured Patients – Patients who have dental insurance coverage will be required to pay their estimated co-payments at the time of service. A copayment is the amount that insurance does not pay based on the percentage of fees covered by the plan, the usual and customary fees that the insurance company follows, deductibles, and plan maximums. We will only file for primary and secondary plans. You will be responsible for paying remaining balances in full when a claim is still unpaid after sixty (60) days.

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● Returned Checks – If any checks are returned by the bank, we require that the check be immediately reimbursed in cash. A $50.00 returned check fee will be charged to your account. Your account will then be placed on a cash only basis.

 

● Broken Appointments – We require that at least twenty-four hours notice be given on appointment cancellations. If you do not arrive for the appointment, a minimum fee of $75.00 will be charged to your account. Patients who have broken more than three appointments will be put on a same-day appointment basis.