Financial Policy

Thank you for choosing Oak Grove Dental Center as your dental care provider. Our office is committed to providing you with the best possible care. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment.

We accept the following forms of payment: Cash, Check, Visa, MasterCard, Discover, American Express, and Care Credit.

Preferred Method of Payment:*

If dentures, partial dentures, or crown/bridge are to be fabricated by a dental laboratory, payment in full is due at the time of impression. If we are billing insurance, the claim is sent after the final appliance is delivered.

For minor patients, the parent that accompanies the child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-paid before the appointment date or previous arrangements have been made with the front desk staff.

Checks that are returned to our office from your financial institution are subject to a $35.00 returned check fee. This fee covers the processing fees that are charged to our office.

As a courtesy, we will bill up to two dental insurances on your behalf. Please understand that we will provide an insurance estimate to you prior to treatment, however, it is not a guarantee that your insurance will pay exactly as estimated. Insurance coverage is subject to limitations, exclusions, waiting periods, frequency, age restrictions, deductibles and maximums which are your responsibility. Please contact your insurance company for detailed information regarding your benefits. Your insurance company and your plan benefits ultimately determine the amount paid. We will do all we can to ensure your estimate is as accurate as possible. Your estimated insurance benefit may differ due to a number of reasons, specifically related to your plan.

All charges you incur are your responsibility, regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you and your insurance company. Our office is not a party to that contract.

Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates.

Deductibles, co-payments and co-insurances are due at the time services are rendered. Insurance payments are ordinarily received within 30-60 days from the time of filing a claim. If your insurance company has not made payment within 60 days, we may ask that you contact your insurance company to make sure payment is expedited. If payment is not received or your claim is denied, you will be responsible for paying the full account balance at that time.

We will cooperate fully with the regulations and requests of your insurance company that may assist in the claim being paid. Our office will not, however, enter into a dispute with your insurance company over any claim.

I understand that all coinsurances and deductibles are due at the time of service:*

YesNo

I understand that insurance estimates are simply an estimate and they are not guaranteed to pay accordingly:*

YesNo

I understand that I am responsible for payment in full if my insurance fails to pay:*

YesNo

I understand that unpaid balances will be assessed a 2% monthly finance charge after 30 days:*

YesNo

By signing below, I acknowledge that I have read and understand Oak Grove Dental Center's financial policy.

Patient Name*

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Name of Responsible Party (if different than patient):

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Signature of Patient or Responsible Party:*

Financial Policy

Payment for Services

Insurance Billing