Please read this document carefully as it sets forth your financial responsibility for the services you receive in this office.
As with any healthcare profession, the patient receiving the service or the patient's legal guardian is responsible for all charges incurred. We accept cash, personal checks, MasterCard, VISA, Discover and Care Credit. Additionally, we gladly accept payment for your services from a family member with that person's approval. All payments, including credit and debit card payments, for initial, ongoing and completed services are non-refundable. We are happy to discuss special payment arrangements, in the event extensive dental treatment is needed, such as outside financing with third party companies.
CREDIT CARD
We accept Visa, MasterCard, Discover and American Express. The cardholder’s name, card number, expiration date, security code, and card type must be included with the credit card payment.
Fee Notice: All of our current fees are the rates for cash and check (paper or electronic). For payments made with your credit card and debit card, a 3.95% processing fee will be added to your receipt.
ACH TRANSFER
We accept ACH payment (electronic check) directly through your bank account. To process an ACH payment over the phone, we will need your bank routing number and account number.
We are happy to discuss special payment arrangements, in the event extensive dental treatment is needed, such as outside financing with third party companies.
As a courtesy, if you have a dental insurance plan, this office will file dental claims on your behalf with all necessary information. In that event, we may agree to defer a portion of the total charges for a period of up to 60 days with a valid assignment of dental benefits (for amounts that may be payable by insurance). Even if we agree to defer a portion of the total charges for up to 60 days pending payment of your dental claim, the estimated deductible, co-payment portions and amounts exceeding your dental plan benefit period maximum must be paid by you or your legal guardian on or before the date that dental services begin. Our office is certified and credentialed to bill your medical insurance plan to further offset your costs.
You agree to receiving emails regarding announcements and educational services from our office, and you agree to our use of photographs and videos taken from your procedures for educational purposes.
Generally, at your first appointment, evaluation/consultation and X-rays are provided, sometimes on an emergency basis. The fees for these services are due and payable when the services are provided, unless we have agreed to defer a portion of the total charges for up to 60 days with a valid assignment of dental benefits. If, as a courtesy, we have agreed to bill your dental insurance plan, you should be aware that most plans have annual limitations on these types of services, so the fees for these services may become part of your out of pocket expense. The fee for the specialist evaluation only (not including X-rays or other services that may be rendered at the time of evaluation) is $250.00.
Should you decide to discontinue treatment in this office after dental treatment has been initiated, you will be charged for all services rendered to date. Payments you have made for treatment that you have chosen to discontinue are non-refundable. Full payment is due for all completed treatment, regardless of the prognosis or outcome, short term or long term, for any service performed.
This office charges 100.00 for appointments canceled without 48 hours advance notice. For payments made by check, please be aware that any check returned to our office by the bank for any reason will incur an additional service fee of $35.00.
Outstanding charges are expected to be paid in full within 30 days of the invoice date. Finance charges of 1.5% monthly will be incurred on all outstanding balances beginning 30 days from the invoice date. If full payment is not received within 30 days of the invoice date, you will also be subject to a late payment fee of $30.00. In the event that your account becomes delinquent (any account that remains unpaid for more than 30 days will be deemed delinquent), you agree to be responsible to pay all costs of collection. This includes, but is not limited to, a $30.00 fee, all fees assessed by a Debt Collection Service (if we contract such services), and all attorney's fees. You should be aware that a collection action on a delinquent account includes the reporting of your debt to the national credit bureaus, which may adversely affect your credit standing.
A signed copy of this financial policy and payment agreement will become part of your permanent patient record.
I have read and agree to the terms outlined in this financial policy.