I hereby guarantee payment in full of any and all fees in consideration for dental services I am responsible for. I understand that I am responsible for all fees not covered by my dental insurance including deductibles and co-payments. I understand payment is due in full for those fees at the time service is performed.
As a courtesy, we contact your dental insurance provider to check your benefits and submit claims on your behalf. We are not responsible for and can make no guarantees as to the coverage your dental insurance will provide. As the patient, it is ultimately your responsibility to know your dental insurance and benefits and you are responsible for any balance that is not paid by dental insurance. We require that all patients, with or without insurance, pay for their treatment at the time of service. We will be happy to file a pre-determination prior to any treatment to your insurance so we can get more of an accurate estimate of what they should pay, but it is still not a guarantee of their payment.
*In an effort to control the cost of our dental fees, we do require a 24 HOUR NOTICE to change or cancel a scheduled appointment. This charge of $25 per hour you were scheduled will automatically be applied to your account.
*We pride ourselves for being on time for your appointment and we ask that you do the same for us. Arriving 15 or more minutes late could result in having to reschedule. More than 3 failed appointments could result in dismissal.
*The office will charge $30 for a returned check. In the event of a returned check, we reserve the right to have you pay in cash for future visits.
*If the account is turned over for advanced collection services, the patient or responsible party will be expected to pay all collection fees ($50 fee), court costs, and reasonable attorney fees.
In order for you to be seen in our office, you must sign our office policies.